25
Examination of witnesses
Kate Murdock, Dr Harri Fisher and Caroline Shepherd.
Q104 The Chair: Welcome to today’s meeting. This is the 10th oral evidence session as part of the committee’s inquiry into childhood vaccination rates in England. I thank Kate Murdock, Dr Harri Fisher and Caroline Shepherd for attending today to give us evidence.
The session is open to the public and is being broadcast live. It will subsequently be made available on the parliamentary website. A verbatim transcript will be taken of the evidence and published on the parliamentary website. If our witnesses find any small mistakes or corrections that are needed, please let the staff know as soon as possible. If, after this evidence session, you want to clarify anything, send us any additional information or amplify any points that you have made, you are very welcome to send us further evidence after the event. If there are any votes in the Chamber, I will have to suspend the broadcast briefly while members go and vote, but we will start up again afterwards.
Let us go to the first question. What are the key trends and disparities in school-aged vaccination coverage in your areas in recent years? What are the key reasons for these trends?
Caroline Shepherd: I am the Assistant Director for School-Aged Immunisations and Child Health and Immunisation Services across the east of England. I am employed by the Hertfordshire Community NHS Trust. Across the east of England, we go from the most deprived area in the country to some of the most affluent areas in the country. The outcomes for children are dependent on what area you are in and what school you are in. Sorry, would you mind repeating the question again?
The Chair: What are the key trends and disparities in the school-aged programme? What are the key reasons for those trends?
Caroline Shepherd: Since the Covid-19 pandemic, there has definitely been a downward trend in the uptake of school-aged immunisations. That is not all focused on anti-vax activity, which accounts for about 3% of what we are seeing across the east of England. The rest I would describe more as hesitancy, with more of a need to provide bespoke services for children and families.
Overall, we can expect to see an initial uptake at first offer of around 80% or 85% across the east of England, whereas we would easily hit 90% or 95% pre pandemic. However, with the right commissioning in place, which I feel we have in the east of England, we can offer an evergreen service, continual catch-up and bespoke services designed around our contract. For example, in Peterborough, we are used to getting 55% at first offer; by year 13, we hit 95%.
Kate Murdock: I am a General Manager at the Trafford Local Care Organisation, which is part of the Manchester Foundation Trust. That is for nought-to-19 public health nursing services. I look after all health visitors, school nurses and specialist services under that umbrella. I am also here as an Expert Advisory Group Member for the School and Public Health Nurses Association, so I have two hats on this afternoon.
I would echo what Caroline said about the trends in our area. We delivered immunisations within the Manchester Foundation Trust until last April, when it was re-commissioned to a different provider. We were easily seeing 85%, 90% or greater uptakes, but, since Covid, they have definitely declined. It was much harder to reach those sorts of uptakes. It was taking a lot more time and engagement with children, young people and families.
It is a really complex picture. There is a lot of vaccine fatigue after the pandemic. There is a lot of vaccine hesitancy. Our young people take a lot of their information from social media, and there is unfortunately a lot of misinformation online that is shaping their views.
Our inequalities are getting wider. Our disadvantaged groups are harder to reach, such as children in care, looked-after children and those who are under complex safeguarding and youth justice teams. Those who are educated outside of the school environment are slipping through the net and are even harder to reach.
There are challenges in the funding and service reductions, and potentially changes in commissioning models and how services are being delivered. There is a general distrust of vaccines by some very high-profile figures, which unfortunately filters through. It is very complex. Generally, there is a lot of misunderstanding and a lack of time for communicating with people about the benefits of immunisation and the safety of the programmes.
The Chair: We will get into all those things as the session progresses. I welcome Dr Harri Fisher online. If you want to intervene at any point and add something to what other people are saying, please do not worry about putting hands up or anything like that—just say what you have to say. Perhaps you could introduce yourself and answer the question, please.
Dr Harri Fisher: I am a Research Fellow based at the NIHR Health Protection Research Unit at the University of Bristol. I have been working on projects aiming to address inequalities and the uptake of the HPV vaccination programme since 2011.
As I do not deliver vaccination programmes, I am just going to talk more generally about the national trends or the conversations I have had with immunisation teams across the country. I hear from immunisation nurses that, since Covid, there has been a big drop-off in uptake of the adolescent vaccination programmes. My conversations with people in the community really show me that there is a lot of mistrust in the healthcare system and in the Government delivering the vaccination programmes.
That has stemmed particularly from underserved communities’ experiences during the Covid pandemic. This is a conversation that still happens within communities. Whereas people would probably have accepted vaccination and not really questioned it before, through the Covid pandemic, decisions about vaccinations became a community event. Lots of people were talking about it, and people now see vaccination as more of a choice. That comes through in this lack of trust for the reasons behind the vaccination programmes. This is not just the school-aged immunisation programmes; it is across lots of different vaccination programmes across all ages.
I have not seen the evidence to back this up, but I am sure that the inequalities will have particularly widened for communities from global majorities. I also hear from immunisation teams that there are big concerns around those young people who either are home-educated or do not attend school regularly. We know that more young people are being home-educated or not attending school regularly than previously, which really makes the work of the immunisation teams much more difficult.
The Chair: I believe that you have done some research by speaking to young people about their attitudes to vaccination. What has that shown?
Dr Harri Fisher: I mostly speak to young people between 12 and 15. Their attitudes often reflect their parents’ attitudes. If they come from a family with low confidence in vaccinations, those young people will often reiterate those beliefs. That is not every young person at that age; there are definitely some young people aged 12 or 13 who have very different opinions from their parents. It is generally a family attitude at that age but, as they get older, their beliefs differ more from those of their parents.
Q105 Baroness Cass: I am getting a slightly different flavour between Kate and Harri. I am wondering whether the distrust comes more from children who are competent in social media or competent online. That is what I thought I got from you, Kate, but you, Harri, said that it comes from the parents.
The other thing that comes across is that there is much more distrust by the time young people are in their teens than perhaps in the early vaccination programme. Is that accurate? Will those same parents who have vaccinated young children be more cautious when they get older? Sorry—that is very complex, but it just feels like a very different flavour from what we heard about the initial infant ones.
Kate Murdock: That is a difficult question. There is still mistrust of certain vaccines. We still find, for example, a lot of mistrust around the MMR vaccine, which is obviously a legacy from many years ago. It carries through. I think Caroline would echo this. We still work on parental consent, even with the teenage vaccine schedule, because there is a fine line about competence to consent at that age. Most of the parents we speak to have not had any vaccines historically through the child’s life-course.
Q106 Baroness Browning: Harri, may I pursue a little what you have just told us about the profile of this group of parents with younger children who are more likely not to want vaccines? If you look at the age group of those parents, I think you said you were looking at nine to 13 year-olds.
Dr Harri Fisher: Normally, I speak to young people between 12 and 15, but the vaccination programme is for 12 to 13 year-olds.
Baroness Browning: Take an average of the age of those parents at the time of Covid. This is just a theory that has come into my head; I am interested to know what you think of it. It was that younger age group that had a lot of difficulty during Covid. The older population seemed a lot happier about having the Covid jabs but, let us face it, with the younger ones, there was an issue around blood clotting with the initial Covid jabs. Do you think that this is a carry-over from that generation who faced some challenges in deciding whether to have a Covid jab, which is now being passed on to the children? If you think that that is feasible, how do you overcome that? It is real experience, is it not?
Dr Harri Fisher: I understand that things were changing very quickly in the Covid pandemic, but, having spoken to people from the community, when the vaccination programme changes or the vaccine is changed, people become very mistrustful. It makes them think that the scientists or the people making the decisions do not know what they are talking about: “Why are they changing it?” It may not come from a place of understanding that, as new evidence is gathered, we can make better-informed decisions.
I agree that, particularly for the slightly younger adult cohort, they may not necessarily see the Covid vaccination programme as benefiting them as much as the older cohort; that may well be influencing those decisions further on. Also, lots of vaccinations have been added to the vaccination schedule, and people now see them as a choice. Because there are more vaccinations, it feels like people are less likely to believe in the importance of the particular vaccination that they are being offered.
For example, during pregnancy, many more vaccinations are offered. Pregnant women are offered flu and pertussis; I think that they are also offered RSV now. This choice of vaccination almost takes away the value of being vaccinated because, every few months, you seem to be offered another vaccine. People get tired of being vaccinated. It is not a particularly pleasant experience having an immunisation put in your arm, and sometimes you can get side effects as well. Lots of people talked about the side effects of the Covid vaccination, so that is still a memory that people have at the moment.
Baroness Browning: I know that I am generalising here but, from where I am sitting, that group of parents are still quite young people themselves, are they not?
Dr Harri Fisher: Yes, slightly younger.
Q107 Lord Randall of Uxbridge: Who is responsible and accountable for improving the uptake of school-aged vaccinations? How could responsibility and accountability be strengthened? As part of that, how effectively do the different partners in the system—including commissioners, providers, local authorities and schools—work together to help improve coverage? Is there any room for improvement there?
Caroline Shepherd: It has to be a whole-system approach from early on, as you say. If we think about the under-fives programme specifically, we see a decline in vaccination rates once parents start going back to work. It then becomes a convenience thing, and there is not necessarily a correlation between those who are opting out aged under five and those who are opting out once they reach year 8 and year 9. They opt out for a variety of different reasons. Young people nowadays seem older than ever. They make their own choices. We often find that, if they do not want the vaccine, whatever their parents say, that is the decision the family goes with.
We are also seeing more needle phobia. We are talking about bringing in mental health services. SEND children are disproportionately impacted, because parents want them to be offered a bespoke service in how vaccines are delivered to them. It definitely needs a whole-system approach, including schools and GPs. Everybody who comes into contact with a family should be able to have a vaccination conversation with them.
Kate Murdock: I entirely agree. A lot of it is about convenience. If you are not able to make a session in your school, there might be catch-ups, but they might be quite a long time down the line. You may forget. You need the capacity to walk into a GP surgery, pharmacy or anywhere that would be able to give that vaccine at the right time. We have experience of people approaching their GPs, asking for the vaccine and being turned away because they are not commissioned for it. That is not acceptable. We need to make it accessible for parents and young people.
We need to think really differently about how we deliver vaccines. We implemented a programme in Trafford many years ago where we vaccinated young people in our special schools with their key workers, but the commissioning contract got narrowed so we were not able to immunise the adults at the same time. The only reason why that was successful was because those young children trusted the individuals who were sitting and having a vaccine at the same time as them.
We need to improve communication. As a school nursing service, we now feel quite separate from our school-aged immunisation provider, since it was commissioned to a different provider last year. We need to look at how we can improve communication.
We also need to improve our IT systems for the whole vaccine programme. When we did our MMR catch-up, starting 18 months to two years ago, we had thousands of unimmunised children on paper. After many hours of trawling GP records, paper records and immunisation cards from families who had moved here from other countries, we increased our immunisation uptake significantly. It was not that the children were not immunised—the information was not in the right place. We cannot carry on with a system where some information is held in a GP practice and other information is held in a child health information system. That will be key moving forward.
Q108 The Chair: Kate, your organisation clearly took responsibility for moving forward with coverage. Is that the normal level of accountability and responsibility being taken for improving the situation, or does it vary in different places?
Kate Murdock: There is probably variability depending on time, money and staffing, because it is hugely time-consuming.
Dr Harri Fisher: I agree with the whole-system approach. It is not one particular organisation that needs to take responsibility for improving vaccination uptake. Schools play a really key role in getting their young people vaccinated. I feel strongly that the profile of vaccination needs to be raised in schools to motivate schools to support families in providing consent, enhancing how the vaccination is communicated and prioritised within the school setting. However, it cannot all fall on schools. They have their own priorities as well, so there needs to be joint working with immunisation teams and with the correct commissioning, trying to provide capacity for immunisation teams to build relationships and restore trust in the communities they work with as well.
Q109 Lord Randall of Uxbridge: I am a little confused. I understand that you are all working together and doing your best on this, but who is ultimately responsible? Let us say that uptake does not increase or falls down again. Who has to say, “We’ve got to work harder on that”? Is it one organisation? I am not saying for one minute that this would happen, but would there be a potential passing of the buck?
Caroline Shepherd: School-aged immunisations are commissioned on a cost-per-case basis. You build your model on what you predict is going to happen. If you fall short of that, you risk financial clawbacks at the end of a financial year—then your organisation is in a bit of a sticky bother, if you like, because it is not sustaining itself financially. That is where some of this falls down. Cost-per-case modelling works really well when you have a captive audience and you can get the numbers in. It is designed to improve uptake, but it does not serve the health inequalities agenda or when you need to do something different. Ultimately, it sits with the provider, but we are at risk of providers walking away if the commissioning is not sustainable.
Kate Murdock: There is also a role for our directors of public health as key drivers of the public health agenda in our public health workforce. I know that there is a lot of movement with health visitors piloting immunising, for example, but it is about how school nurses and health visitors, as leaders of the healthy child programme, can be supported by directors of public health to deliver messages. Ultimately, it sits with commissioners because, if they are not commissioning the right model, it is going to be difficult to deliver.
Caroline Shepherd: I just want to add one more point. The east of England is commissioned on a cost-per-case basis plus a block contract, so there is a realisation that, if you want to address the health inequalities gap, you need to pay for it and fund it. We get the numbers through the cost-per-case part of our contract, then there is an element of working with communities and individual families to provide the evergreen offer, as well as community cash help provision and even home visits. Where it does work, our data shows us that that works.
Q110 Baroness Andrews: Caroline has answered my question but I have a couple more. When you look at the difference between your situation and others, the decline has obviously been more rapid elsewhere. The east of England has held up better than many areas of the country. You said in your first piece of evidence that you had the right commissioning, which you have now described. How does that commissioning differ from, say, the commissioning in Trafford or any other comparable area, where there may be less forecasting or the financial arrangements work differently?
Caroline Shepherd: The way I understand it is that, for most immunisation contracts, including those that sit with GPs, for every vaccine you give, you get a price per item. That can range from £10.06 to up to £15 or £16, potentially. That is the way it works. If you do not get the numbers through the door, you do not get the income, but you have of course employed the staff to deliver the programme. In our contract, we are very lucky that it was recognised that you need a block payment that is protected and cannot be clawed back to address health inequality issues.
Baroness Andrews: Has anyone asked you whether you could universalise your system, rather than the other negative one? Is this something that has been drawn to the attention of the DH, for example?
Caroline Shepherd: I would like to think that our commissioners, Dr Ellie Powers and Ruwan Wickramasinghe, have done that, but I cannot guarantee it. I certainly speak to a lot of people a lot of the time. We were just Hertfordshire, then we expanded across the entire region to roll out that model.
Baroness Andrews: That is really interesting. My question for Kate is a bit different. You made a powerful case for school-based immunisation. For the children who are outside of the system, you have covered special schools. There is also home education. The increase in non-attendance in schools, post Covid, is troubling. Have we any idea of what proportion of children are outside now, in this context, and are therefore at greater risk than they would have been pre Covid?
Kate Murdock: I do not have the numbers to hand but I would echo your concerns. It is always challenging to understand who is not in education settings. We have challenges with our local authority colleagues because of data protection in sharing who is not in school, which is a huge frustration because these are often the most vulnerable children.
In Trafford alone, many new alternative provisions have popped up over the last 18 months to two years to meet the needs of children who are not able to be in mainstream school. Trafford is a relatively small borough, and we have over 40 alternative provisions, which might take only a handful of children, but some are getting 30 or 40 children who have emotionally based school non-attendance, SEND and, typically, some neurodiversity. Being able to reach all those children is really difficult.
Baroness Andrews: What sort of providers are they?
Kate Murdock: They are private providers.
Baroness Andrews: They are private health providers.
Kate Murdock: They are private education providers.
Baroness Andrews: Right. So, even if they were visible and people knew about them, there would be no guarantee that they would say, “One of the things we have to do is make sure that these children are vaccinated”.
Kate Murdock: We put everything that we possibly can in place. When we hear that a child is not in school, we write to them. We contact them and offer the normal school nursing service, which includes all of that promotion around immunisation, but a lot of families choose not to accept it. Because we are not a statutory service and we are not mandated in any way, we cannot do anything but make that offer.
Q111 Baroness Freeman of Steventon: I want to pick up on something you said, Kate. If I understood rightly, you said that, when you went through all the paper records and all the records held in different places, you found that a lot of children who were showing as unvaccinated on GP systems were actually vaccinated. Do you know roughly what proportion turned out to be vaccinated but had been marked as unvaccinated?
Kate Murdock: It was roughly 10%. We had over 1,000 children on the list and we found over 100 who had been vaccinated, so it was quite significant. It might have been on the GP record but not on the child health system, for example. We uncovered them in lots of different ways.
Q112 Baroness Neuberger: I want to pick up on something you said, Harri, about schools having lots of other things to do so they are not going to put all their attention on this. Is there something that you think can be done to encourage schools? They obviously offer the opportunity to schools, but how can schools be encouraged to take advantage of chasing people who are away from school on the day, for instance? Is there anything more that we could say to schools? Is there more that should or could be done?
Dr Harri Fisher: We have been having this discussion recently in trying to think about how we or the vaccination providers can engage with schools. We have networks in Bristol. It is really about how we can get the vaccination programmes to be prioritised. We were thinking about providing training for staff in schools. It could be the admin staff who are responsible for organising the vaccination programme in that school, but it is about enabling school providers to have confidence in having those brief conversations or being able to signpost families to the relevant healthcare professionals.
I am not sure how it is nationally but, locally, the immunisation providers have changed to an electronic consent method. That is really good in terms of being much more direct and sending emails directly to parents, but it means that the school often may not be aware of which families have or have not returned the consent form. They are not able to target young people in the way they used to with the paper-based consent forms, where they would say, “These young people haven’t returned the consent form. We’ll quickly ask them to get their parents to complete the form”. There is a bit of a gap now where schools may not be aware of which families are engaging or not engaging.
Baroness Neuberger: That is quite worrying, is it not? They cannot be aware because the data cannot be shared once it is on an electronic system.
The Chair: Are you talking about the Mavis scheme, Dr Fisher?
Dr Harri Fisher: I am not sure; I do not know the ins and outs.
The Chair: We heard about it from another witness.
Q113 Baroness Ritchie of Downpatrick: This is a two-part question. In fact, in our last probing questions, we were moving into this area. I want to concentrate on the children themselves. How effective is the education and communication about vaccinations for children and young people? How much do they know about it? You said previously that they gain a lot of information through social media, but are other outlets more instructive for them? How could that level of communication and education be made more effective?
Caroline Shepherd: We find that, with the algorithms on social media, once young people have started watching one type of social media, it takes them down a rabbit hole, so they continue to get these five-second clips of what is doom-mongering a lot of the time.
However, we recently completed a piece of work where we worked with a social communication company. We went into schools and spoke to young people. What did they want to know? They wanted to know everything. They wanted to know all the gore and the facts. We built a health promotion film with those young people to share throughout the east of England. We found that, in schools that allow us to show that video to young people, the uptake rate increases. They are not getting their information from reputable sources. Teenagers do not tend to click on NHS websites; they go into social media land.
It can be effective. We definitely see that, if we are allowed to go in and present at assemblies or as part of PSHE lessons, the uptake rate goes up. It is about getting access to the children and having the right funding in place to get the staff to do that in the first place.
Baroness Ritchie of Downpatrick: Have you thought of ways of getting access to those children?
Caroline Shepherd: Typically, a head teacher will let you into a school if you can get the dialogue going with them and show them what their uptake rate is, where we need to get to, what the optimum herd immunity is, et cetera. They are always willing to let you join one of their lessons, particularly if you come with a lesson plan. That is what we have found really works.
Kate Murdock: There is definitely room for improvement in communicating with our young people, particularly when we are trying to move to more self-consent, because they need to understand the process in a lot of depth. We used to deliver assemblies prior to the vaccines to give them as much information as possible, but, when you are delivering to huge numbers—sometimes up to 300 pupils in one room—there is not a lot of room for interaction, so we try to make ourselves accessible.
There is definitely something that could be done around making a move to make vaccinations and information on immunisations mandatory in the PSHE curriculum. I absolutely agree with Caroline. We would not necessarily rely on our schools to deliver that, but we can be key in helping to support those conversations and lessons.
We also need to consider cultural and language differences because, where we have had difficulties in communicating with our young people, when we speak to our young people and do pieces of work with them, they go home and try to influence their parents. We have talked to them about other subjects, such as vaping. They get excited about that information: they take it home, engage in dialogue and try to shift that agenda.
We need to consider how we can bring this into all the conversations that we are having about improving health literacy across the board, as well as how we can use more toolkits, as Caroline described. We have an immunisation toolkit that SAPHNA developed recently, which has a lot of visual work. We worked with young people to develop that toolkit, and it was what they wanted. It is about listening to what young people want and letting that shape how we move forward.
Dr Harri Fisher: I mentioned the electronic consent procedures. What was quite helpful before, with the paper-based consent methods, is that young people would be handed a leaflet and would get some information, and hopefully that information would go to their parents. With the electronic versions, young people are omitted from the consent process in that way. It may be that some young people are having conversations with their parents about the vaccine, but many of the young people I have spoken to over the years would not have conversations at home with their parents.
I find that what information is given in schools depends on the school and how motivated the school is. Even after they have been vaccinated, lots of young people still do not really understand what they have been vaccinated against or what parts of the body HPV-related cancers can affect, for example.
We have done some work to try to address young people’s information needs. We worked closely with young people from underserved population groups to develop a lesson plan, which we called EDUCATE; that is particularly about the HPV vaccination programme. We partnered up with an organisation called the PSHE Association, which provides PSHE resources for schools nationally. That lesson is available online for school staff but also for members of the public to download. Within the resource, there are lessons; there is a lesson plan. We hope that schools can use that resource as part of their PSHE curriculum.
More can be done to motivate schools or engage with schools to use the resource. We know that our local immunisation team highlights the resource to schools, lets them know that the resource is available and lets them know that it would be helpful for their students, but the feedback I get from the immunisation team is that they do not think that the lessons get used in practice in schools locally.
There are lots of resources out there that could be used, but it is about making sure that they find their way to young people. I agree that, if there were some mandatory requirement for schools to teach about vaccinations in the PSHE curriculum, that could be a way to raise the profile of vaccinations for those young people.
Q114 The Chair: As I understand it, they are supposed to teach it in PSHE. It sounds to me as if they are not doing it. Can you comment on that?
Dr Harri Fisher: They may well be teaching about vaccinations, but perhaps they are not teaching about the specific vaccinations that young people may be having or timing it in relation to when the vaccination programme is delivered in the school setting. It could be that it needs to be organised within the curriculum in advance. You could do a lesson on the particular vaccine, then, a couple of weeks later, the immunisation team comes in. In practice, that does not happen as well as it could.
The Chair: So it is about co-ordination.
Q115 Baroness Freeman of Steventon: I do not know whether you agree, but it strikes me that we are asking young people to question everything they come across online and generally in the world, yet we are not necessarily giving them an opportunity to ask these questions about information on vaccination that might be coming from the NHS. Where do you think this would sit? Where can we make space for them both to ask the questions we are encouraging them to ask about all information and to get answers from people who actually know and can have the conversations that we really should be encouraging?
Kate Murdock: We encourage it in our school nursing service because it is quite a unique service. We are a universal service that is available to every child. I know that there are challenges in some parts of the country. We are very lucky that we have maintained our school health service.
Conversations about immunisations will be had. We previously held assemblies. We then signposted to our regular drop-ins, which we have in all our schools, for further questions. It is about being open and accessible, and signposting to anybody who can answer questions. As I said earlier, we should use our pharmacies and GPs more along those lines as well.
Q116 Baroness Nye: What happens to children in schools that may be resistant to letting you come in to do assemblies? How are they captured? What happens to those children if you cannot get into the schools to have those assemblies or programmes?
Kate Murdock: We did not find any schools that we could not get into. We were lucky that we engaged well with the schools in our area. I know that my colleagues in Manchester had a couple of schools that they could not get into, so opportunities were offered in other settings that were available and near to the school. We did find that that impacted on uptake.
One problem we found is that, occasionally, we had to cancel sessions that were planned because the facilities that schools were offering to us when we went in to immunise were not safe to deliver the programmes in. We set up contracts with our schools about our minimum expectations and what we would need to keep the sessions safe while we were in there. As a provider, Caroline, you probably have some more to say.
Caroline Shepherd: Yes. We set up SLAs with all our schools around that, because we would often turn up and the room would not be big enough or it would be unsafe. They would just put you in a portacabin at the back of the field. They were really unsuitable environments.
We find that teenagers, typically in year 8 or year 9, are almost a little too young to want to have that conversation; I am talking very generally here. The vaccines are given at that age for a reason—that is when research says we should give them—but, because of our evergreen offer and our continued chasing, where we ask, “Would you like it now?”, a couple of years later, the young people say, “I want it now”, and they decide for themselves. They are at more of an appropriate age, where they are willing to have these discussions. I do not know what my colleagues have found, but we definitely find that, the older they get, the more receptive they are to having conversations.
Q117 Baroness Andrews: Kate, can you expand a bit on what you said? You said that you were lucky that your school health services in Trafford held up. I wonder whether you want to risk making a few generalisations about the state of school health services in the rest of the country.
Kate Murdock: Speaking with the knowledge I have from working alongside colleagues in SAPHNA, I know that we have benefited from the support of our commissioners. In some areas of the country, the school nursing service has been depleted and is not commissioned. It might be a very slight commission; in some areas, it is very scarce.
Baroness Andrews: Would SAPHNA be the right organisation to ask if we wanted to find out whether there are qualitative differences in what is available? All of you have talked quite clearly about growing health inequalities. You have described them as occurring for different reasons. Presumably, the poorer the school health service, the poorer the vaccination service that can be expected. Is that a correct parallel, or is that an oversimplification?
Kate Murdock: It may be slightly oversimplified because a lot of school-aged immunisation providers sit outside of school nursing now, but there is a significant role for school health services to play. We obviously have our healthy child programme. There are lots of key points within that programme where we can raise the issue of immunisations. We can assess immunisation status and provide information to support the work of our school-aged immunisation teams. However, because there is no mandation behind that, as there is for health visiting, it makes it very different. We did a recent survey within SAPHNA; I am sure that it would be happy to share the results. There is a very varying picture of school nursing services across the country.
Q118 The Chair: Earlier, Lord Randall asked about accountability across the system. I would like to ask about accountability at the school level. Who is the most capable of pushing forward the coverage of vaccines in a school? Is it the head teacher? Is it the school nurse? Should it be a governor? Should school governors have responsibility for that, or do they already?
Kate Murdock: It would sit with the governing body but it needs support, though not necessarily that of the head teacher. Head teachers are busy educating our young people, which is what we need them to do. Sometimes, it is the pastoral leads and office staff who support the immunisation programme. They are the ones who organise rooms for us and welcome us on‑site on the day. It is something that, from the governing body perspective, could potentially fall within the safeguarding remit, perhaps around safeguarding the well-being of pupils.
The Chair: What is the role of the school nurse in this, then? Is she—it is usually a “she”—responsible for answering students’ questions? She does not actually deliver any vaccines. She does not commission them. She is not responsible for pushing coverage forward. What does she do?
Kate Murdock: As a public health practitioner, it is absolutely core for school nursing to promote anything that addresses health inequalities—that is, promoting good practice around health and health literacy, or working with young people and families to get them to understand the vaccines. They are experts at motivational interviewing. They use strength-based approaches and work with families. Their ultimate aim and objective is to work with children, young people and families to enable them to make choices that will keep them happy and healthy for as long as possible. That is about promoting the vaccine.
Some school health providers still provide vaccination, so it is a different picture. A number of school nursing providers across the country still deliver vaccination services, I believe. They are key professionals in providing that information and education.
The Chair: Do some of them do catch-up services?
Kate Murdock: Yes. That would be included in their commission.
Q119 Lord Dholakia: We have dealt with the question of communication with children and young persons. What is the process of communication with parents? Is it more effective? What happens in relation to parents from diverse communities? How effective are you?
Caroline Shepherd: This takes me straight back to Mavis—managing vaccinations in schools. We were part of the pilot site across the east of England. It is fully NHS-branded, whereas our previous electronic consent was not the standard NHS blue. Those parents get a direct communication from us as a service. I know that we have talked about the school no longer being in control, but the school-aged immunisation provider is in control. It can see who has consented and who has not, and it can chase. We certainly chase. We phone parents the day before vaccination sessions to drive up the rates.
Aside from that, we have an additional function that we call “call and recall”. For any family who have not done this, we will continually try to phone them. It is administrators and nurses, so you can have a clinical conversation with families who are hesitant. That is using all the research that is available to anybody, but it is often about pointing them in the right direction. It may also be about arranging a home visit if there is a complicated situation going on. As I said before, we are talking about only 3% of people being true antivaxxers. The other 10% to 15% need the access and convenience to make it happen for them and their family. It is about having the right commissioning to put that in place.
Kate Murdock: It is about being in the right place at the right time. On your specific question about different communities, we found that one of our high schools had an exceptionally poor uptake of HPV vaccine consent returns, so our school nurses went into the school on a parents’ evening because we knew that parents were going to be there, seeing the teachers and understanding. They took interpreters and consent forms into the school. They more than doubled the number of consents that they had for pupils in the school, and they were able to deliver the vaccines. That was exceptionally successful. It is about thinking differently about how we can meet people’s needs.
We also need to build on what we learned in the Covid pandemic and use people whom communities trust. We worked a lot with our faith communities. We worked a lot with head teachers, because head teachers are often seen as trusted individuals in communities. We did find that, in some of our schools, a lot of people from the community worked in the school, so having the head teachers on board was really beneficial when we were talking to parents and communicating with them. They helped to share the messages. There are things that we can do to improve, but there is lots of scope to learn from things that have been tried on smaller scales.
Dr Harri Fisher: I have worked with global minority parents to find out their information needs. Lots of the parents I have spoken to have big concerns, particularly around side effects of the HPV vaccination programme. Also, they do not necessarily think that the vaccination is appropriate for their young person because of the association with sexual behaviour.
All parents need access to evidence-based information. They need access to healthcare professionals to talk to them. A lot of the families I speak to find it difficult to have that conversation with healthcare professionals. They might struggle to have a conversation with a GP or make an appointment with a GP. A school-aged immunisation team can sometimes be difficult for them to get in contact with, particularly if there is a language barrier or the family is new to the UK and not used to the NHS system.
Sometimes, an email coming from the school or the immunisation team can easily be not looked at or not read. The information may not be presented in an engaging way. It is difficult for parents to engage with that information. We have been working with families and parents to develop a website called HPV Inform. It is a place for parents to access different resources and videos, and to have their questions about the HPV vaccine answered. We have recently made it available in different languages. So there is a resource available, but it is also about working with communities to get the website available and for families to access it. Our immunisation team is sharing that with families as part of their routine communications.
My question is that I am not sure how many families end up clicking on the link that gets sent through from the school-aged immunisation team. It is about thinking of lots of different routes of communication with parents— not just relying on the school-aged immunisation team or the comms from the school but thinking more nationally about whether we can raise the profile of vaccinations through media campaigns. It is about really trying to raise awareness of vaccination programmes for adolescents.
Q120 Baroness Cass: You have already touched on my question quite a lot. You have spoken about the call and recall system, but how could that potentially be made more effective?
We have also spoken a lot about consent. It is almost a bit of a Catch-22, because you said that the time when they get the vaccinations is before they are really able to talk about it, but, as Baroness Freeman said, you ideally want young people to understand what is going into their arm. If young people have had the vaccine at a stage where they have not understood it, and they gradually develop more of an understanding, it is presumably quite difficult, in terms of volumes, to have that kind of conversation with them either at a later date or outside of the normal programme. How do you manage that?
Caroline Shepherd: On the day of a vaccination session, we tend to ask the school to bring down everybody, including those for whom we have no consent form, because we feel that it is really important that they see us, hear us and know where to access us in future. In some situations, we use Gillick competence with young people; that is quite rare, though, and we always encourage young people to talk to their families first. It happens occasionally. However, there are risks associated with that. Typically, it will be a very competent young person whose family does not want them to get vaccinated, so it is quite a bold decision for them to make.
Baroness Cass: How common is that?
Caroline Shepherd: It is quite rare. Our yearly cohort for each year group is around 86,000 children. We are talking about less than 10, so it is quite rare.
On the day, for everyone who comes down, if there is no consent, young people will typically have their mobile phones on them, so we will call the parents on the spot. They will answer thinking that it is their young person, and they will often say, “I forgot to fill it in. Yes, I do consent”, and then we can get on with it. Afterwards, we constantly text, send letters, make phone calls and offer catch-up opportunities to get to the position where we reach herd immunity by the time education ends, but it is a hard slog and costly work.
Baroness Cass: This is a difficult question to answer, but how typical do you think your persistence is of the situation around the country?
Caroline Shepherd: I have not heard of any other area that is commissioned in the same way. There is some bizarre commissioning going on. There is a service somewhere where one provider does year 8 vaccinations and another provider does year 9 vaccinations. Typically, we will go in in year 9 and, if we have consent for men/DTP but consent for HPV is missing, we will offer it at the same time—including MMR and anything else the child is due as part of a MECC offer—but I have not heard of that model anywhere else.
Baroness Cass: Kate and Harri, do you want to add anything to that?
Kate Murdock: Caroline summed it up really well. It is a hugely time-consuming process to do that call and recall, but it is worth it if you have the commissioning to do it.
Baroness Cass: The NICE guidelines say that a child’s vaccination status should be checked at specific educational stages. How consistently does this happen? From what you have said, it is phenomenally difficult because records could be all over the place.
Caroline Shepherd: There is a difference between checking and having the ability to deliver what is missing, as well as having the conversations that go alongside that. You might typically come across a year 7 pupil who has never been vaccinated, so you need a skilled, knowledgeable and competent nurse to work out what is missing and when to give it, because lots of the under-five vaccines cannot be given later on—if you have missed your opportunity, they are done. Checking is different from actually being in a position to be able to deliver it. You would have to walk around with a bag of 20‑plus different vaccines and a fridge.
Dr Harri Fisher: We did an evaluation of changes to consent procedures locally, where the immunisation team did exactly what has been talked about: making phone calls to parents and occasionally offering self-consent for those young people who are competent.
We did some analysis of the data. We found evidence that all those efforts by the immunisation team in having those phone calls managed to narrow the inequalities in uptake slightly. Those families who are less likely to return the consent forms, who are typically from more deprived backgrounds or from minority-ethnic groups, were the families whose young people were then vaccinated as a result of those extra efforts.
Although it is time-consuming, there is evidence that putting that extra effort in can address some of the inequalities. It comes down to commissioning and making sure that the immunisation providers have the resource to be able to chase by going in and having those conversations.
Baroness Cass: It is the 80:20 rule, is it not?
Q121 Baroness Browning: When a school-age child is vaccinated, whether at school or anywhere else, what do you give a child that says, “You have just had this vaccination on this date”? What are they actually given?
Caroline Shepherd: Nowadays, they do not get anything physical. It goes into their NHS record, which can be seen on the NHS app.
Baroness Browning: You do not give them anything.
Caroline Shepherd: No. A conversation is had about what is about to take place, what it is for and the side effects, but they do not get a typical Covid card, for example.
Baroness Browning: I have asked previous witnesses this because, at preschool age—I am going back a bit—we used to get the card and the record. Mums usually kept it, in the main. There can be all sorts of questions asked later as to what you had. Everybody has forgotten and nobody in the home is quite clear—never mind what is on the record and where it is. Do you think that there is any incentive, particularly with mobile phones, to have some sort of app that records it once a child has had a vaccine, no matter at what age or where?
Caroline Shepherd: The NHS app does that already.
Baroness Browning: But you do not immediately give it to them. You just said that, on the day they have the vaccine, nothing happens.
Caroline Shepherd: What happens is that you record it on Mavis, if it was in the school, then that populates into the NHS app overnight.
The Chair: Not in Wales.
Baroness Browning: What I am thinking of more is whether there is anything that would make it attractive for a young person or a teenager to collate their own record. It would be a very good practice for them to start recording their health history themselves. The idea is that a 14 year-old is going to go on the NHS app. I cannot imagine that that is their first port of call when they get home. Is there no incentive? If they all did it, everybody would do it, would they not?
Caroline Shepherd: No, there is no incentive. We start to talk to them about going to university or travelling, which is when they will need their vaccinations. In year 8 or year 9, they are not really thinking about the future too much. They are slightly too young, we find. They are too busy punching each other in the queue—particularly the boys, with all due respect to them. Yes, I like that idea.
The Chair: I am aware of a particular school that received a very large box of mugs to give to the children when they had had their vaccination. The school thought that it was a terrible waste of money. It would rather see the money be spent on the vaccine service than a whole lot of what it described as “tat”. So there are downsides to giving people something. I used to get a sweet when I had a vaccination when I was little, I think.
Caroline Shepherd: The younger ones get a little certificate for the flu vaccine. They quite like that. We are talking about four, five, six and seven year-olds.
The Chair: It is not for teenagers.
Caroline Shepherd: No. They are a bit too cool for that.
Q122 Baroness Hodgson of Abinger: Thinking about inequality and some of the harder-to-reach communities, what effect do literacy rates have on this? If we are sending home forms and things to parents who cannot read, they are probably not going to react out of embarrassment.
Kate Murdock: It is a huge issue. We know that the average reading age across Manchester is eight. We are sending quite complex information, if we are sending links. We also have a lot of families who live in digital poverty. We are expecting them to click on links or scan QR codes more and more. That has a role to play. There is definitely something around having evidence-based information on platforms that people can access, or perhaps audible information that does not rely on reading quite so much.
Baroness Nye: On that point, we have heard from other witnesses that the use of SMS, which is a good way of receiving information, is being withdrawn. Is it being withdrawn in your areas?
Caroline Shepherd: No, it is not. We use it more than ever for health promotion, walk-in clinic opportunities and direct bookings. When we rolled it out, we found an uptake. We found that lots of younger cohorts and younger parents are digitally dependent. Their phone will read aloud to them or translate for them. They do not have to wait for a physical letter to come through the door. If you are a new mum, you typically go and stay with your family when you have just had a baby. There are also travelling populations that move around, for example. There is another cohort, which is the digitally dependent cohort.
Q123 Baroness Neuberger: You have already talked about a lot of what I was going to ask you about in terms of catch-up programmes for school-age children who have missed vaccinations, including whether and how they could be made more effective. The thing we have not talked about completely is the role that other providers could have in all this. Could GPs do more? We have talked about schools and school nurses. What about GPs? What about pharmacists? Are there other players in this system who could—and, you might argue, should—do more?
Caroline Shepherd: Yes, I think so, but you have to have the data right, because you must come across as a trusted source. If you start talking to somebody about where their missing MMR vaccines are when they have had them already, you are building up distrust again. The data has to be right. We are missing opportunities when children go into A&E, for example, which teenagers typically do with all sorts of injuries. If a vaccine record is available, A&E is in the perfect position to offer a catch-up at that point. Catching up is key.
Baroness Neuberger: That is a really good point about A&E. I chair UCLH and the Whitt, and our A&E departments are full of teenagers. I do not know what they manage to do to themselves, but they are full of teenagers. Kate, do you want to say anything on this?
Kate Murdock: Yes. I agree completely. We need to build on the back of successful things such as Pharmacy First and enable pharmacists to be part of that as well. Young people will access pharmacies for vaccinations when they are going travelling, so why not for the core routine programme?
Baroness Neuberger: This all requires a really good record, does it not?
Kate Murdock: Yes, a robust data system that is shared.
Caroline Shepherd: It cannot be at the risk of disrupting school-age programmes. Do not look for HPVs in year 8s; look for them in year 9-plus.
Baroness Neuberger: Absolutely. Harri, do you want to say something on the evidence base around this?
Dr Harri Fisher: There is not really an evidence base around pharmacies. We were hoping to explore that through research, but we did not get the funding. Certainly, pharmacies are a really good option for young people. They are trusted. They are conveniently located. They are often close to their home. They might walk past quite often. They can have drop-in appointments. Pharmacists are used to talking to young people about sexual contraception, so they are used to having those conversations with young people without parents necessarily getting involved and providing consent. Pharmacists would be a great place for the HPV vaccination programme or the adolescent vaccination programmes to be delivered.
It is really about thinking about the capacity of pharmacists and making sure both that the commissioning is in place and that they are getting sufficient funding to make it worth while. Without a financial incentive for them to do it, it just will not happen. Pharmacists are already delivering lots of different vaccination programmes. They are very trusted professionals to deliver vaccination programmes.
Q124 The Chair: Is there an issue around stocking the right vaccinations, if there is an expectation that A&E departments can do opportunistic vaccination? They go off, do they not? They have a use-by date. Is there a danger of wastage? The same, I suppose, applies to pharmacists.
Caroline Shepherd: There could be. The other danger is that A&E staff are there for a reason. They have their own staffing model. In our area, what we find works is where we send an immunisation nurse from our immunisation team into the hospital to be in A&E or on the wards for teenagers—for any age, actually. They are protected from the front-line services that the hospital is trying to deliver, and we have the back-up of all our fridges and all our stock.
The Chair: Are they there all the time? That must cost a lot of money.
Caroline Shepherd: They are there from Monday to Friday. They can deliver everything from zero to 80.
Baroness Neuberger: That is so clever.
The Chair: How common is that?
Caroline Shepherd: I do not think that it is done much wider than the east of England.
The Chair: How interesting.
Baroness Neuberger: That is very clever; I am going to pick that up.
The Chair: It is very interesting.
Q125 Baroness Nye: As you know, this committee will make recommendations in its report to the Government about how to improve the uptake of childhood vaccinations and reduce disparities. In your view, what should we be prioritising? What are your top three priorities?
Caroline Shepherd: My top three priorities—this probably comes as no surprise—would be around the commissioning design. There should be dedicated immunisation services with enough well-led, knowledgeable, competent and confident nurses. That is the front door to immunisation services. It builds public trust. If you have a fragmented system where people do not know when they can access, how they can access or what is being said to them, and the records are not right, that is the first barrier.
On top of that, I believe that the evergreen offer and the MECC offer are really key. We offer multiple visits to schools and continuous catch-ups. We are constantly chasing by text message, phone calls and, in some situations, letters. We also offer specialist bespoke offers to SEND families, safeguarded children, home-educated children, et cetera.
As an example of this, we could have a catch-up clinic where grandma comes in with dad and a couple of children. We might have invited one of those children, but we are reviewing the whole family, and we will offer catch-ups for everything that is due. There is real convenience there for the family and the community. Word soon gets out. We have a choice of booked appointments or walk-in sessions all the time, across the whole of our region.
The next thing is data. I know that we recently got Mavis, but it is about the interoperability of immunisation data and not letting it be locked down because of consent issues with sharing. It is a public health dataset that needs to be shared between everybody.
The last thing is getting access to immunisations given abroad. We have a system where parents can send in records and we update their records for them.
Kate Murdock: I would mention data and IT systems. We need something that is informative for practitioners and cuts down the logistical challenges in understanding who needs the vaccines and who they should be targeting. It was absolutely uplifting to hear about Caroline’s model of delivery because we do not feel as close to our immunisation provider as we would like to be. The immunisation providers need to be more closely linked—I would obviously say this—with our public health nursing services. We lead the healthy child programme, and imms are an integral part of that. We need to be working much better together.
There is something around how we train our workforce—across the whole system—in a stepped approach. This is for anybody who is working in that arena, from teachers to pharmacists and GPs. We need some sort of training programme for all professionals involved.
There is also something around how we can put evidence-based information on a platform where children, young people and parents will access it. We see so many negative influences on social media where immunisation is concerned. We need to get the positive voices to balance that out a bit.
Dr Harri Fisher: I have a couple of things to mention. It is complex, but we need to restore public confidence in vaccination programmes. We need to address families’ questions and concerns, particularly around the safety of vaccination programmes, while giving the message about the benefits of vaccination. We need to make sure that the information is available in different formats, with accessible information and audio information, and in different languages. We need to have lots of different ways of getting that information out there, thus raising the profile of adolescent vaccination programmes through different people and in different ways.
Also, you have to make it really easy for people to get vaccinated. Although most young people will get vaccinated at school, for those young people who do not get vaccinated, how can we make it really easy for them to get vaccinated? Is it walking in at the pharmacist? Is it making sure that the commissioning is in place for the GP to provide the vaccine, if a young person or their parent takes them to their GP?
It is also about thinking of more innovative ways to support young people to get vaccinated, such as pop-up sessions in colleges. Again, the barrier to that locally is that the commissioning is not in place. It is really about having flexible commissioning. Immunisation nurses and teams need to be able to be innovative in how they deliver vaccination programmes. They need to be responsive if the community is saying, “There is this event. You could come here”. We need to enable immunisation teams to do that.
Q126 Baroness Andrews: Harri, you have not mentioned the importance of research funding. Some of the work you are doing is so innovative. Are you getting any funding from government to do any of this, or is it all from private foundations? Is there a need for a strategic research programme? Sorry—I am putting words in your mouth. Tell me what you think.
Dr Harri Fisher: Most of the funding that we get for our research projects is from an organisation called NIHR, which is a government body. Certainly, there is less funding available at the moment. I mentioned the work that I wanted to do around pharmacists. We have applied a couple of times but we have not got the funding for that; I am currently aiming to rework that application and put it in somewhere else.
The message that I am hearing from other researchers is that the competition for funding is increasing. Lots of people are getting applications rejected at the moment. That is our perspective.
Baroness Andrews: Does that funding platform add up to a strategic funding programme funded through government? Are your findings going back into innovation strategies for the NHS or some intelligence pool that is going to be made available? Do you have a clear sense of the connection between your research and policy development, shall we say?
Dr Harri Fisher: Some of the funding bodies that we apply to have particular calls and themes. Recently—in fact, currently—there is an improving vaccination uptake-themed call. There are definitely avenues that come around relating to vaccinations, which we apply for.
Q127 Baroness Nye: As you know, there are going to be changes in commissioning. We are moving to ICBs. From what I hear, Caroline, you have a very good system in place. Are you worried about what the changes are going to bring? Will they be helpful? Kate, will the changes help or hinder what you are doing currently?
Caroline Shepherd: I am worried. In moving it down to the ICB level, there is a slight conflict. I have to be careful about what I am saying here.
The Chair: Please be honest.
Caroline Shepherd: It is difficult to manage GP contracts, and what we have currently works.
Baroness Nye: Sorry—it was not meant to be a tricky question.
Q128 The Chair: We have a couple of minutes left. I wonder whether I can take you back to something that Baroness Cass asked about earlier: the NICE guidelines that a child’s vaccine status should be checked at specific educational stages. I am not very clear on whether it happens, what stages those are and whether it is helpful.
What if schools were expected to ask for the vaccination status of the applicant child when they apply for a place at the school? This could perhaps go right back to nurseries, primary schools and secondary schools—and, of course, for children coming at various stages from other areas. Is there an appropriate level to ask what their vaccination status is?
I recall one of you saying that it is all very well knowing what their status is but you have to be able to do something about it if there are gaps in it. How could that be done? Would it be an effective nudge to the parents to look into the child’s vaccination status, as well as they can, if they have their red book, their app or whatever? Would it be helpful? Has it been tried? Is there any evidence?
Caroline Shepherd: Typically, when parents need to check the immunisation status of their child, they call their GP to get it. That causes a rush on the GP. They might also try to contact their immunisation provider or their local child health department.
It would be more effective if local authorities could share school admissions data with their child health service, which happens across the east of England. The child health service, which is in effect a great big database of the children with all their screening and imms, could share who is missing what with their immunisation provider, which could then offer that to the families. It would completely cut the school out and take the pressure off of the children, GPs, et cetera.
The Chair: Sorry—I just want some clarification on that. Who would do that checking?
Caroline Shepherd: Have you heard of child health information services?
The Chair: Yes.
Caroline Shepherd: They could, quite simply, run reports. We have this in our region. They produce great big files, which they email across to their imms provider. Those files tell them about all the children and what they are missing. The imms provider then contacts the families to arrange a catch-up.
The Chair: Is it appropriate that that should be done at that stage, just before the child is about to mix with a whole lot of other children they have never met before?
Caroline Shepherd: Yes, absolutely. I feel that it should be done at that stage. Child health has a call and recall responsibility up until the child is five. It seems to fit quite nicely.
Kate Murdock: We do check. We check when a child enters reception. We send out health screening questionnaires and use them as a reminder. We also do new parents’ evenings at the school. We always talk about immunisation and making sure that children have had their full vaccination programme, as well as any preschool boosters that are needed before they start in school. So we do check.
To some extent, it would be helpful. I know that a lot of private nurseries are now asking for immunisation status. Parents are getting increasingly used to being asked for that. I know that a lot of schools send out health questionnaires when children start school. It is something that could easily be added. It is about data sharing, as well as who gets that information and who acts on it. Believe it or not, we struggle to get class lists from schools to be able to offer our programmes.
The Chair: Is that a misunderstanding or a correct understanding of the rules around data sharing?
Kate Murdock: I would say that it is a misunderstanding, but schools’ data controllers can be exceptionally cautious.
The Chair: If there are no more questions, it falls to me to thank all three of you very much indeed for coming—especially those of you who have come at very short notice. We are most grateful to you. This has been a very useful session. That is the end of the session.
