18
Examination of witnesses
Dr Nick Thayer and Caroline Smith.
Q129 The Chair: Welcome to today’s meeting. This is the 11th oral session as part of the committee’s inquiry into childhood vaccination rates in England. I would like to thank Dr Nick Thayer and Caroline Smith for attending this afternoon; they will introduce themselves in just a moment. The session is open to the public and is broadcast, and it will subsequently be available via the parliamentary website. A verbatim transcript of the evidence will be taken and it will be published on the parliamentary website. A few days after the session, you, our witnesses, will receive a copy of the transcript to check for accuracy, and it would be very helpful if you could advise us of any small corrections as quickly as possible so we can get it up on the internet. If, after this session, you wish to clarify or amplify any points made during the evidence session, or you have anything additional that you want to send us, you are very welcome to submit those things to us. I am going to ask you the first question and I would be most grateful if you could just briefly introduce yourselves for the sake of the broadcast.
The first part of the first question is quite short, but I then have a supplementary for each of you. The question is: could you set out the roles of your providers in the delivery of pre-school and school-age vaccination programmes? Caroline, would you like to start?
Caroline Smith: My name is Caroline Smith. I am the joint clinical lead for Northumbria Health Care NHS Foundation Trust, and I lead the school-age immunisation service.
From our point of view, we deliver all of the school-age programmes and support the UKHSA with any outbreaks—it could be hepatitis B, it could be MMR—to try to do that call and recall. We deliver across an area of about 2,500 square miles, with a cohort of about 140,000 children to reach. Regionally, we cover Newcastle, Gateshead, Northumberland and North Tyneside.
Dr Nick Thayer: Good afternoon. My name is Dr Nick Thayer. I am head of policy at the Company Chemists’ Association, which is a trade association for multiple pharmacies across Great Britain, and our members own and operate around 4,000 community pharmacies. We also host the Pharmacy Vaccinations Development Group, which brings together officials and everyone in the entire vaccine supply chain to look at how community pharmacies can get involved in more vaccine programmes and use their presence to increase uptake across the country.
Community pharmacies at the moment have both a private and an NHS-commissioned role in childhood vaccinations, and it is worth noting that, on the private services, there is not much data or information available, because it is all commercially sensitive, but there is a good portion of the population that will pay to access vaccinations through community pharmacies.
From an NHS point of view, there is limited commissioning at the moment. There have been some really good exercises with MMR and polio vaccines previously in response to outbreaks, but the most prominent one at the moment is childhood flu, for two and three-year olds, which was commissioned the winter just gone, and, with relatively limited preparation time, community pharmacies vaccinated over 47,000 two and three-year olds over the winter. One of the challenges which I suspect I will come back to is that it is now June, and we do not yet know whether we are going to be asked to do that again this winter. That is a challenge.
Q130 The Chair: I am sure we will come back to that. I have a supplementary for you, Caroline. Can you tell us what are the trends in uptake of vaccinations among preschool and school-age children in Northumbria, including through the core and any supplementary and outreach provision, and what are the main reasons for those trends? While you are about it, a question has arisen among the committee about school nurses. You will undoubtedly be in contact with school nurses, or your team will. We are hearing something rather disconcerting: that although we are aware that most school nurses look after more than one school, it could be that not every school has a designated school nurse. Is that true in your experience, and what effect does it have on your work?
Caroline Smith: Yes, that is true. In Northumberland, our school nursing and health visiting service was commissioned through a different NHS provider, who remodelled their school nursing model. There is very little scope within their role. They have a three-tier model of what their health priorities are within the schools. Vaccination is talked about, but with the surge in mental health issues and neurodiversity within schools, and the challenges in mainstream, their focus has shifted dramatically. From our point of view as an immunisation team, obviously, after the Health and Social Care Act, the school nursing teams as such were dissolved and split. You had your school nursing service and then there was the onboarding of the immunisation teams.
In Northumbria, from our point of view, we are keeping up with the national trends or we are ahead of the national trends. Some of that is because of our philosophy—what we do with our team, after Covid—but we have to remember that, when I started as lead for this team, our national uptake was around 70% for flu and every year that figure has decreased, because we have to be realistic about what is actually achievable. This year, our figure was 50% in high school children and 60% in primary school children, and we had an overall uptake which hit that target. It is becoming a lot more work to achieve those targets. It is a lot more public-health driven. We cannot rely at all on just getting forms back and delivering what we have. We are having to do a lot more just to keep ahead of the curve or even stay on the curve.
The Chair: You say that you have seen a small improvement. What do you put that down to?
Caroline Smith: We have a philosophy. One of the first things I did with Stephanie Gibbs, who is our joint leader, was not popular. She came from a school nursing background, and my background is in health visiting, so we are both specialist community public health nurses. We had to make an organisational change with the team pretty early on. It was a team based on the old school-nursing model, and that was never going to work if you are looking at building community capacity and having a public health outlook.
The first thing we did was to look at their hours. A lot of our very valued nurses worked term-time only and often around school hours. Our families were telling us, “Actually, that doesn’t suit us”, so we did an organisational change, and our nurses now have core hours of 8 or 8.30 am to 8 pm. We knew that to meet those community needs we would have to put late-night clinics on, and we do clinics on Saturdays. We also target specific groups within the community and codesign a lot of our work. Our nurses are not going to be trusted voices—they see a child for about five minutes—so it is about asking what we have, what huge assets are out in the community already, whose are those trusted voices, and can we work together in partnership to try to make this better?
Q131 The Chair: Dr Thayer, can you tell us what the evidence is on uptake of vaccinations delivered through pharmacies? What lessons could be learned for the childhood vaccination programme from pharmacy delivery of adult vaccinations?
Dr Nick Thayer: What you see in community pharmacy services, regardless of which one it is—this applies just as much to vaccination services—is that community pharmacy offers access, location and presence. Community pharmacies are often open in the evenings and at weekends; as Caroline said, it is really important to work around people’s busy lives. Community pharmacies are located in supermarkets, high streets and health centres across the country and, because of the positive pharmacy care law, there are more community pharmacies in the most deprived parts of the country. For every clinical service, including all the adult vaccination programmes commissioned nationally, you get more activity in the most deprived places, which is where it is really needed.
Just under half of all Covid vaccines last year were provided from community pharmacies. We did some work looking at Covid activity in 2024 and saw that, in some of the key groups that we are trying to reach out to—Black British, Asian and others—over half of the vaccines were from community pharmacy. That is because of where community pharmacies are and the long-standing and trusted relationships they have.
A really interesting study was commissioned in Tower Hamlets, where community pharmacies were specifically tasked to reach out to their local populations—the patients coming in every month to collect their regular medication—and to have proactive, targeted conversations with them about vaccination. There were about 3,000 people, over half of whom decided to get vaccinated, and over half of those got vaccinated there and then in the community pharmacy.
Pharmacy is where it needs to be; the challenge is that it is often not commissioned to do the thing it needs to do. That goes back to my earlier point. The 10-year health strategy for the NHS committed that, in 2026, community pharmacies would provide HPV vaccines, as, I assume, some sort of catch-up programme. That is quite exciting and timely. During the pandemic there was a group of children who were not vaccinated, for obvious reasons, who now need to be vaccinated. There is a ticking clock on that. It is now June, and we do not know what will happen with that; we do not know when it will be, who will do it or how it will work. A sense of urgency is needed, as well as continuity.
The Chair: How long do your members need to prepare?
Dr Nick Thayer: It is difficult to say because it very much depends on how it will be commissioned; that could be really important. Whether it will be commissioned nationally or will be a local pilot really changes things, but when community pharmacy is asked to do something, it is usually quite good at turning things round quickly and delivering, as we saw with the childhood flu vaccination. The challenge is, with the stop-start nature of commissioning, that it is very difficult to get settled. It is difficult to change the public perception of what pharmacy does, for patient pathways to be embedded and for that message to spread.
The adult flu programme started off quite small with around a couple of hundred thousand vaccines; it is now at nearly 5 million, and it grew year on year. That is because it takes time for these things to bed in. You are asking private businesses to commit to a whole new thing, and they need to invest in that and prepare—to do that instead of other things. That requires some decisions to be made and a bit of certainty that all that work will still be useful next year and the year after.
The Chair: I suppose it also takes a while for the public to know that they can get those particular vaccines at your shops.
Dr Nick Thayer: Absolutely.
Baroness Andrews: May I follow that up before I move on to my other question? In relation to the delays that you are experiencing—you explained it very well—who are you communicating with? Where would the final decision come from? If, in desperation in a month’s time, you really needed to know, who would you talk to?
Dr Nick Thayer: It is difficult, because we are not quite sure how it will be commissioned. The childhood flu vaccination programme last winter was commissioned nationally, so that would have sat with the NHS, as a key decision-maker, along with UKHSA and the department, and I hope that it will be the same this year. The vaccination strategy sets out intentions for ICBs to commission, so, if and when that becomes the case, I would expect the decision to sit there.
Baroness Andrews: So, basically, you do not know whether it will be NHS England or the ICBs which will kick in in time. They are not supposed to—
Dr Nick Thayer: There is a bit of uncertainty.
The Chair: Could I ask you to speak up a bit please, Nick? You have a very nice gentle and quiet voice, but it would be really helpful for those of us with hearing aids.
Dr Nick Thayer: Yes, of course; no problem.
The Chair: Thank you, and sorry to interrupt.
Q132 Baroness Andrews: My question is partly about the context and partly follows up on what you and Caroline have said already. The 2023 vaccination strategy set an aim for childhood vaccinations, which was a core offer in primary care and schools, and then a supplementary and outreach offer. You do not theoretically fit into that description. Where do you see the weaknesses of that approach? In particular, how do you see pharmacies being able to supply, given capacity and distribution issues? How would you critique that in terms of your own service?
Dr Nick Thayer: I say first that the vaccination strategy was really good and clear. What it did really well was to set out what is national, what is regional and what is local, and that clarity is really helpful, although we are moving towards that. Certainly, from a pharmacy point of view, as a result of the strategy we have seen commissioning for RSV, pertussis and childhood flu in quite a short period of time. We are quite pleased with that.
What is also really important are some of the digital developments that have come from that. As a result of a lot of work within NHS England, community pharmacy vaccine programmes are now almost fully integrated with NHS systems, from that point of view. That is working really well. The challenge will be, if and when vaccination happens at a regional or even at a lower local level, to make sure that there is consistency across the country, because we do not want to see unwarranted variation between different parts of the country. Why would it be that in one part of the country it looks one way, and in another part it looks different?
Baroness Andrews: Some of the evidence on that point is very interesting. It suggests that, as you are dealing with the same demographics, the question becomes not so much whether you are able to address inequalities but whether you are providing additional choice. Do you think that you could develop your service so that it could be targeted more effectively—so that you could pick up on some of the inequalities?
Dr Nick Thayer: By commissioning community pharmacy, you increase capacity for the system, access to the population and choice. That is quite clear. As pharmacies get more established in delivering these programmes, they get much better at proactively reaching out to their patient cohorts and saying, “This is something we offer”. As mentioned, one of the challenges we have seen with the stop-start is that it is very difficult to say, “This is something we offer” when you are not sure whether you will be offering it.
With Covid, we have seen that, where pharmacies are now pretty well established as part of the local system delivering the vaccine, they are very good at proactively reaching out to people and saying, “This is something we offer”. They have patients who they regularly go back to each year to remind them of that, and they have systems using prescription delivery and other tools to promote what they are able to deliver. There have also been some really good examples of pharmacies doing outreach activity such as pop-up clinics at local mosques and community centres. That is really effective at reaching certain population groups, and you can tie it in with other activities such as blood pressure checks, or whatever.
One of the challenges is that outreach activity costs extra and it can be difficult for a business to take on if they are not sure that they will make a return on it. There is a risk of it becoming a loss-leader activity and, with pharmacy funding where it is, that is not something that pharmacies can easily choose to do. What worked quite well during the pandemic was that there was a core offer available to everyone, and then there was ring-fenced funding for additional outreach activity. You could say, “I’m going to do my basic offer, and I want to do this extra thing here for this group”. I have not seen many examples of that for routine vaccines; that would be really interesting to see.
Baroness Andrews: That is interesting because, presumably, what you are looking at is a lot of innovation on the part of individual pharmacies. Can you collect that sort of data? Can you collect good practice? Can you scale it up? That is one question.
I have another question. In your written evidence, you were sceptical about the role of pilots; I think that you would rather see something that is systematic and universally available. Can you elaborate on that a bit?
Dr Nick Thayer: Yes. On this point about pilots, a pilot shows that something is possible. It does not show what it could do. That is an important distinction to make. If you pilot something and community pharmacies deliver a vaccine programme for six months, that shows what you can deliver in six months, but it does not show what will happen if you let it be for a few years and people get used to it and know what it is. That is one of the key challenges I see in what is happening at the moment.
Also, when pharmacies are where they are, they have to make decisions. Do they want to commit wholeheartedly to a pilot that may end at some point, or do they want to focus on something—say, Pharmacy First—that is established and has an equal benefit for the population? There is that juggling exercise. One of the challenges with pilots is that they should be used to prove feasibility, not to prove benefit. That is being mixed up at the moment, I think.
Q133 Baroness Andrews: That is very interesting. Caroline, can I ask you a similar question? First, let me say that you have done so well in Northumberland, especially in terms of measles and the MMR; the things that you are doing are highly innovative. I do not know whether you are in a position to spread your good practice. How would you be able to do that? Do you think that you have got all the low-hanging fruit? Are you getting to some of the really difficult groups in society now?
Caroline Smith: I think that we are. That has come from a real, dogged determination to turn this into not just an immunisation service but a public health service. We work with a lot of minority groups. In 2024, we won the PEN award for our work with the Jewish community. We worked with the local Jewish rabbi and the local trusted GP to look at uptake of the HPV vaccine; that community did not want to take up that vaccine because it was associated with sexual activity.
When we rolled our contract out into Gateshead, the first thing I did was contact the Jewish Community Council of Gateshead. I asked, “Would you teach our staff, so that it’s not a case of us just coming in and delivering it in your schools? Could we have some teaching?” What that does is build the first level of respect. They were really happy to tell us all about that Jewish Orthodox community, including what was important to them and why. We are on an electronic consent system but we cannot use that because of their Sabbath, so we put everything on to paper. It is about taking those early steps, and we have done that really quite well.
The other thing that we are really proud of is where we are veering away from being just an immunisation service. We work with a local charity called Amber’s Legacy, which is a cervical screening charity; it was set up by somebody in the community who lost his daughter at 27. I was really passionate about our nurses in Amber’s Legacy because I knew then that, if they were fired up by Amber’s story, they would go out and do some great work. We did a joint video with Darren from Amber’s Legacy. It got more than 112,000 views and was shared more than 1,000 times. Stories came from the comments, with people urging women to get cervical screening. It started to snowball.
Now, we do a lot of joint work together because those children are coming into the clinics for an HPV vaccination but the parents and the mums are there. Do we then have that conversation? We do not stay in one lane; that is one thing that we have never done over the past five years. Every opportunity is an opportunity to promote public health. We are just starting to get into those really marginalised communities in the west end of Newcastle. There is a community group called Haref. Our nurses will go in there and sit down and have a cup of tea. We are also looking at redesigning all of our posters so that they are in people’s native languages, with the name of their rabbi or their faith leader on there as a point of contact—not us but them.
Baroness Andrews: That is very interesting and, may I say, very inspiring. Going back to the rather boring general question, I asked about where you fit into the national strategy. Can you conceive of a bigger role for schools? What would it require? What would it consist of?
Caroline Smith: Absolutely. We have had some funding this year from our local immunisation steering group to roll out the flu jab to two and three year-olds in nursery. I could never understand why our nurses were walking past a mainstream nursery and not offering it. We were really well supported by Northumberland County Council and North Tyneside Council. We have increased the uptake in that cohort in North Tyneside by 15%, and we have increased Northumberland’s uptake by 8%. Some 80% of the feedback—this is really important if you are co-designing and co-producing—from the families said, “This is brilliant. I can get all of my children vaccinated at school together. I don’t have to think about the little one”.
However, when we did the evaluation, there was a marked evaluation showing that a vaccination strategy at the local level is the strategy to go for. Some of the feedback was fabulous. Other bits of the feedback said, “I just don’t think they’re ready to be in nursery on their own and be vaccinated. I’ll go to the GP”. The other evaluation was, “I took mine to the pharmacy because it works around me. I can go after work and my local pharmacy can do it”.
Although I went in and created this pilot with the fantastic team of nurses that I have, I really wanted us to come out as top dog. I will be honest with you: I wanted our service to be the service that was best placed to deliver this. The caveat is that only 40% of our population end up in mainstream school nurseries. Some 60% are away from that; they are in private or kinship care or are with their parents. We cannot have our hands on everything.
From our point of view, we would love to see the work of the school teams being celebrated and them learning from each other. There is no national picture for clinical needs to come together. We have it regionally—we share information around the region—but I know that we are going to talk later about commissioning and its impact on innovation.
Q134 Baroness Neuberger: You have explained where all the difficulties lie and some of the ways of getting through them—as well as, obviously, the great successes. You might say that the commissioning and funding arrangements are rather strange and a bit piecemeal. Can you tell us how the commissioning and funding arrangements support the delivery of childhood vaccinations, particularly in terms of the supplementary stuff that I know you are doing and the outreach offers? Can you also tell us how they could be improved? That is really important for our report.
Caroline Smith: Similar to Nick, we do not know what we are commissioning for—especially in flu—until very late on, when the schools are closed. We have had a few years when it has been for reception through to year 11, which was nice. We hedge our bets and assume that that is going to be the case.
There is no funding in that financial envelope for any of the public health work that we do. Stephanie and I have to make some tough choices about cost efficiency and savings in that non-pay budget. When all of our information is submitted, it is data driven, so there is very little opportunity to tell people what we do, in terms of your supplementary point as to why we are successful—
Baroness Neuberger: Can I interrupt you for one second? This is really important for us. You say that you have to make some very tough choices and work out how you can use your money to get that message out there; you do get that message out there, but it is not funded. Can you give us a couple of examples? That would be really helpful.
Caroline Smith: One example is the comms for the Jewish HPV vaccine. We wanted to put out posters with QR codes. We had to go to a charity and ask for some funding to be able to have those posters printed. Our mileage costs are quite high. We cover 2,500 square miles, so we have had to look at alternatives, with car sharing and pool cars, which we now have. Because our geography is so diverse, up in rural Northumberland I can ask my nurses to go to three schools in one day. If you need four or five nurses for one school but only a couple to go on, then it becomes quite problematic.
A lot of our support is done with the good will of our nurses. They will work additional hours. They work part-time, they are not getting paid overtime, or they will work and take time off. That is great and I am really proud of them for that, but it is not sustainable and it should not be: we should be able to reward them for the work they are doing.
Baroness Neuberger: Dr Thayer, do you want to add anything?
Dr Nick Thayer: I will briefly say that the funding arrangements work well, so pharmacies are paid for the vaccines they do—and the more vaccines they do, the more they get paid. That is quite a good incentive mechanism to get pharmacies to work harder on that. What we have seen over the years, particularly with flu, is increasing innovation from pharmacies looking at different ways to reach different populations, and that has been successful.
I have already made the point that outreach costs extra, and we have had some examples where pharmacies have wanted to do things and conversations have not happened with the timeliness needed to have the impact we want and that has fallen through. A bit more of a proactive approach to recognising that and creating that pot would be really helpful.
To build slightly on what I said earlier around the commissioning approach, we need to have a national structure and framework for vaccines: “If a pharmacy is going to deliver this vaccine, this is what it looks like”. There is a definite argument to say that not all pharmacies should do all vaccines—I think that is fair—but when a pharmacy is delivering a vaccine, it should look the same everywhere in the country. I think that is really important in creating a standard approach.
Baroness Neuberger: Just because we are focusing on childhood, is there anything you would say specifically about what should be done about commissioning vaccines within pharmacies for children?
Dr Nick Thayer: To deliver childhood vaccines in pharmacies, pharmacies will probably need a little more time to prepare. There are different considerations for that, and different communication strategies will often be required. That is why I am particularly worried about the HPV approach because it is a different cohort, so we will need a slightly different approach and it will take longer to get ready. But, ultimately, I am confident that pharmacies have the capacity and capability to do so.
Q135 Baroness Hodgson of Abinger: Can I just dig in a little further? I am not in the business, so it may be that I do not have a full understanding. When they commission, do they commission a particular company’s vaccine, and do you have a choice in that? You said you wanted the same delivered throughout the country, so who decides what company is going to deliver a certain type of vaccine? Do you find that the pharmaceutical companies approach you about delivering vaccines and encourage you to use their products? How does that all work?
Dr Nick Thayer: In terms of the commissioning itself, there are probably two standard routes at the moment. The first is what is called an advanced service, where any pharmacy able to do so will apply to the local ICB and inform it that it is going to deliver the service: “This is what it looks like, every pharmacy is doing the same. That is what adult flu looks like and that is what childhood looks like this winter”. That has been quite successful, so all pharmacies are able to engage in that if they choose to do so. As a result, around 90% of pharmacies are providing adult flu and around 30% of pharmacies have provided childhood flu.
The other approach is through an enhanced service. It will be a case of: “This is what it looks like, it is the same everywhere in the country”. Then the local regional team will make decisions on which pharmacies will be commissioned to do so. Pharmacies will apply and say, “I would like to provide this service”, and a decision will be made based on access, take-up in the local area and where the gaps are, and then they will choose pharmacies on a variety of local metrics.
I will address your point about the pharmaceutical companies. I have had many conversations with pharmaceutical companies, and they are keen to look at examples of best practice and see how they can be shared across the country—we have really good data and context. Decisions about which vaccine products to use sit with UKHSA and do not have much to do with pharmacies. There are some conversations, but they are separate from the commissioning entirely.
Baroness Hodgson of Abinger: Does the decision about which companies are going to provide vaccines for particular types happen at a commissioning level?
Dr Nick Thayer: There is guidance provided by UKHSA as to which vaccines should be chosen, and what is first-line, second-line and third-line.
Baroness Hodgson of Abinger: When you say first, second and third, is that if there is not enough?
Dr Nick Thayer: “For this patient, we should use this one if it is available and if it is not, they should get this one as a second choice, and this will be the third choice if those are not available”.
Baroness Hodgson of Abinger: For particular patients? Is that because they are of particular ages or have particular conditions?
Dr Nick Thayer: Yes. If we take flu, for example, if you are over 65, we would use this vaccine; if you are under 65, we would use that vaccine. It is those sorts of things.
The Chair: That all comes from UKHSA?
Dr Nick Thayer: Yes.
The Chair: That is a very good point. Can you tell me, is there equity in the funding between community pharmacies and GP practices for one and the same vaccine?
Dr Nick Thayer: That is a really difficult question to answer, because it is a bit like comparing apples and oranges. The payment for vaccines sits alongside a wider contract, which works in a very different way and funds lots of things slightly differently. GPs are paid on a per-capita basis, based on their population lists, and there is a host of expectations within that. Pharmacies are paid generally on an activity basis for things like their dispensing, and there is a host of things within that: things like the rent, the rates and the staff costs are all tied up in that, so it is difficult to compare the two things directly, but the activity rates are comparable.
The Chair: We now move to data questions from Baroness Freeman, who is online.
Q136 Baroness Freeman of Steventon: How well do current data systems support the delivery of childhood vaccinations, including your supplementary and outreach offers? What do you think are the risks and the potential benefits of reforms to data systems, such as the introduction of the single patient record, for childhood vaccinations? How can the benefits best be realised and any risks that you foresee best mitigated? Nick, will you go first?
Dr Nick Thayer: Okay. I mentioned the NHS vaccination strategy earlier. As a result of that, the capacity and capability within community pharmacies’ digital framework has transformed in the last two to three years. A patient can now see the vaccines that they may book through the national booking service, which is an NHS system, and they can see a variety of pharmacies where it is available. They can book, the pharmacy will see that, and it can then order the necessary stock it needs from central warehouses.
When a patient comes in for the vaccination, they can use something called the record a vaccination service, RAVS, which is an NHS-built product, to record the vaccine itself. At midnight that night, the vaccine is updated directly to the GP record and to central databases. From a pharmacy point of view, the entire journey is completely integrated with the entire NHS system. Admittedly, it is a bit clunky at times, because the services are a bit new and are still being worked on and developed, but the framework is all there and it works. It is available for every vaccine that is commissioned by the NHS and could be turned on for other vaccines.
One particular challenge for pharmacies is that the national booking service does not talk to the diaries that pharmacies have for everything else they do, whether it be their private healthcare, their NHS-commissioned work and their routine stuff. So at the start of every day, you have to pull out your national booking service and your own diary and compare the two. I do not think that people are using pen and paper, but they are certainly having to copy across, and that does create an admin burden, with risks of double appointments and missed appointments. Integration is the last real big step in smoothing out that journey, and I know that NHS England is working on it, but it is on a long list.
As for the single patient record, I am not sure how much immediate benefit it would have, because we are already connected up quite nicely. I think it will be important that that is continued and that all professionals accessing the single patient record are able to see that vaccines happened in a community pharmacy. To be honest, I would expect that to be routine.
Baroness Freeman of Steventon: Just to be clear, you can see all the vaccination records of anyone who comes into a pharmacy? You can see that they have had their childhood vaccinations?
Dr Nick Thayer: At the moment, a pharmacy can see all the vaccines that it has been commissioned for. If I am commissioned to provide the RSV vaccine, I can see whether a person has had it. I also have access to the summary care record, which provides some additional information.
Caroline Smith: The transfer of data is a real challenge. We have an electronic consent programme, which is brilliant for us. It is great for me for data capture, and it is really convenient for the nurses. That is run overnight and goes straight on to the SystmOne record for child health. But if the child goes elsewhere, we are not necessarily aware of that. If you look at a child’s health record, you will see that there is a vaccination grid, but if the vaccine has been provided by other providers, it is hidden away; you have to search for it in a third-party portal.
We delivered 80,000 flu vaccines in eight weeks, including 3,500 in our community clinics, and the difficulty is that our nurses have a finite amount of time to see a child, make sure that they are fit for vaccination and then vaccinate and process them, so we do not have that information. Quite often, dad brings a child to the GP surgery one day, which does not let us know, and the child has a double vaccination because those systems do not talk to each other.
It is a challenge. As a team, we can mitigate the risk of double vaccination because of our system. If the vaccine is given by our team the first time, they cannot get that child’s record back to give them a second vaccine, but we just cannot see that when we are dealing with such volumes of people. A single patient record would suit the school services a lot more—sharing information on the children from the cohorts that they have access to.
If it was up to me, I would build a system with “stop and pause”, whereby if somebody goes to vaccinate a child and there is a vaccination registered against their NHS number, it would come up with a stop and pause message—a bit like the prescribing portals in the hospital—which says, “Stop. This child has this batch number”. That would mitigate not just the reputational risk of double vaccinating, and having families upset and having to be reassured that it is okay, but the cost implications. HPV vaccines cost about £112 each; they are not cheap and you do not want to waste them or give them unnecessarily.
From a school point of view, I can see how pharmacies and primary care are a lot more linked in, but we are very much on the periphery.
Baroness Freeman of Steventon: The electronic consent that you mentioned is quite an efficient way of doing it—when parents are able to do so. What about the downsides to that, either for people who are not so digitally active or where that cuts out an important person within that loop—such as school teachers who might not be aware of which children have been vaccinated and which ones they might need to chase up because they know that consent might be forthcoming if a little follow-up was done?
Caroline Smith: We do quite a lot with our schools. Admittedly, some schools are far more on board with us than others, which is always a help. We have a system whereby we get the class lists from the schools first and we ask the schools to put the initial information out through parent mail. I have been asked about this before, but it sends the right message that it is not just health; it is education. We then cross-reference those class lists and, a week later, non-responders get an NHSNoReply message.
Part of that text messaging is about using some behavioural insights that I read up on, on MMR. We tell people that it is a free vaccine. If you have come into this country from one with a health system where vaccination is not free, it creates that barrier. Then, if all else fails—we cannot do this with flu vaccines because we do not have the capacity—we do verbal consents for teenage programmes such as HPV, diphtheria, tetanus, polio and meningitis.
I got the data from the team on Friday. For the HPV vaccine, we telephoned 2,800 families and increased the uptake by 12%. There is a real drive for having those conversations over the phone, the old-fashioned way. The problem with that is that, with the new commissioning, you can do that only with a band 5-registered nurse, so I cannot ask my admin team, who speak to families all the time, to take consent. They cannot do that; it has to be a registered health professional. I do not have the capacity to put band 5-registered nurses in my office and ring families, even though we know that it works.
The Chair: We had a piece of written evidence which suggested that the system goes straight to the parents, asking for electronic consent, bypassing the school student. Given the age of those students—they are Gillick competent, are they not?—it does not help with their education and the control of their own health if that happens. Have you come across that?
Caroline Smith: Yes. We do Gillick competence. We tend to do it when we cannot get parents to agree. The UKHSA guidelines say that if two parents cannot agree, you hold back and wait until they do. That does not happen in the real world, as we know, so we will go through the Gillick competence with that child.
From our point of view, what we wanted to do was to change hearts and minds, and you do that through the families. Those children who are Gillick competent are happy to consent and take control of their health, which is fantastic, but it is almost hidden because they know that their parents do not agree. It is about public health messaging, changing perceptions and looking at the demographics of parents. There are lots of things influencing this. Our parents are younger and they are part of the social media generation, so there is a lot of work to do. We do not rule it out; we do it on a case-by-case basis.
The Chair: But it is only when you have not had a response from the parents.
Caroline Smith: It is if we have not had a response. We have just turned the HPV programme on its head, so that we target all the out-of-syncs until year 11, even though the HPV vaccine is due to be given in year 8. We target anybody who is unvaccinated until the day they leave school. We go into year 11 and do Gillick competence, because we do not want to lose them. Once they have stepped over the school gates, we have lost them. There is work ongoing with that, but we are at well over 95%—we are at about 97% by year 11. We have changed our consent. It used to be that consent forms were valid for a year; now, a disclaimer is ticked to say that the consent is valid until the student leaves school. That takes out another layer of bureaucracy for the families.
Q137 Baroness Neuberger: You said that, before, you could use your admin staff to have some of the conversations with parents, and they talked to families all the time, but now you are not allowed to—it has to be a registered health professional. Did you get an explanation for why that change was made?
Caroline Smith: There is a general consensus, post pandemic, from the findings of feedback from the pandemic, but we have not had a decisive answer.
Baroness Neuberger: That is really helpful, thank you very much.
Baroness Cass: Can I ask a supplementary on that? Would it be possible for the admin staff to ring and do a lot of the legwork, and for the consents to be signed at the appointment, so that they have captured them, at least?
Caroline Smith: The problem with that is that the guidance we have been given is that it has to be a registered professional who can talk through all the risks and benefits at that time. The only time a nurse would say that is at triage, if there were any health questions that needed to be asked. It is not ideal.
Baroness Neuberger: No.
The Chair: All these vaccinations are free for eligible people, but do any eligibility issues come up? The question is whether someone is eligible for a free vaccination, and if you are not sure about that, how would you find out?
Dr Nick Thayer: The short answer is, “No”. The longer answer is, “Not in our experience”. For many vaccine programmes, eligibility is based on age. Age is something that can be confirmed quite easily with the patient and with the access to various records that we have. Where there are other criteria, such as being clinically vulnerable or otherwise, from using the information that is available to them—whether it is access to records or looking at the medicines they take—pharmacists or pharmacy technicians can usually determine age; they can also do so from just talking to the patient. Cases where it is difficult to confirm eligibility would be edge cases, which are few and far between.
Q138 Baroness Ritchie of Downpatrick: Obviously, at the conclusion of all our evidence-taking, our committee will make recommendations to the Government on how to improve childhood vaccination coverage and reduce disparities. We have had some very good evidence today. In your view, what should we prioritise?
Dr Nick Thayer: First, pharmacies need to be commissioned to deliver more vaccine programmes as quickly as possible. They also need to be commissioned in such a way that they can have confidence that the commissioning will last, so that they can make the changes and investments that are necessary to create the full potential and deliver for the population.
I would also say that the NHS should prioritise the integration of the national booking service with all of its existing services. That should be quite an easy thing to fix, but it would have significant efficiency benefits.
Finally, we have not touched on funding much, but, ultimately, funding is really important for general community pharmacy and vaccination programmes overall. The benefits of the Government putting additional money into all vaccine programmes, regardless of the programme or the provider, are significant to the health of the population and to all the metrics that come with it. It is such an important public health action, and it needs to be well funded.
Baroness Ritchie of Downpatrick: When you talk about funding, what quantum of funding are you talking about?
Dr Nick Thayer: There are probably better people than me to say what it is but I would say that, the more you put in, the more you get out.
Baroness Ritchie of Downpatrick: You are playing safe with us.
The Chair: We have had some difficulty in getting figures on cost effectiveness for any of these vaccine programmes.
Caroline Smith: I agree with Nick. When our contract comes up for renewal, it is renewed for five years, plus the possibility of another two. You are constantly looking at that financial envelope to try to make it fit, rather than at what you can deliver. We depend very much on the support of our trust to shoulder some of the overheads, costs and things like that.
We also need a real recognition of the qualitative side of the service and not just the data, because the data is only the data because of the work that is pushing behind it, so that, within that financial envelope, we have the resources to go out to these marginalised groups and do an awful lot more.
I think we all know that, with the 10-year plan, we are moving from secondary care to primary care. Community resilience means that we have the appetite to deliver that and be a really big part of it. There are teams that want to do this work. It is about thinking about more than just, “You have to have X number on your block payment, then you are paid per vaccine”. You talked to Nick before about the costs for GP practices of delivering vaccinations and pharmacy. I can tell you that, in Northumberland, GPs get paid to do HPV catch-ups, and they are paid twice as much as we get per vaccine. So it is also about discrepancies like that.
The other thing, from a school imms point of view—I have not touched on this today—is really close working with the Department for Education because we are guests in schools. Some schools support us fantastically, but some schools will not let us over the door. At the moment, we have a situation, which we have raised with UKHSA, where an academy trust—a SEND school for very vulnerable children—will not let in any school teams from across the whole of the north-west region. They will not provide us with class lists because they say that it is a GDPR risk, but these are really vulnerable children and we do not know that they exist because we cannot get over the door. We need that power of entry. If only I had a pound for every time our services have been prevented going in because the school photographer is going in and that is more important; that gives you a flavour of what we deal with quite regularly.
We need a joined-up message from the Department of Health and Social Care and the Department for Education that says, “Actually, this is a really important service, and they need to get in to do the job”.
The Chair: That is a very important point. What proportion of schools in your area take that approach, would you say?
Caroline Smith: We have 498 schools, including SEND schools and mainstream schools. We also have alternative provision, which is really challenging: you have children who come in for two hours in the afternoon on one day and in the morning on the next day, so trying to capture them is really difficult.
I understand some of the wariness around that, in terms of trying just to keep these children in education, but I would say that that is not true of the majority. We have a new nurse system, where we work really closely with schools and try to build those relationships up. It was really difficult post pandemic, because they had their own agendas to deal with and those were really challenging times. We were respectful of that but, five years on, we would like to see this being part of head teachers’ agendas. I do not know what the carrot to make that happen would be.
Baroness Cass: Apart from the banal, such as the school photographer being in, what do you sense as being the reluctance? What is driving it?
Caroline Smith: Belief in our service, maybe. We do not know who is on the end of the phone. We do not know what their personal beliefs are.
Sometimes, schools are in crisis. They are firefighting every day, so we are just something else that they have to organise and plan. You can almost hear the heavy shoulders on the other end of the phone.
I have had head teachers say to me, “This is health. It shouldn’t be going on in my school”. There are lots of different reasons. We are really respectful of the tough job that high schools in inner city areas have. We have some primary schools where they have 52 different languages and they are firefighting every day. That is probably where we are coming from.
The Chair: I thank you both very much for the very useful information you have given us today. With that, I am going to bring the session to a close.
