20
Examination of witnesses
Caroline Temmink and Ian Perrin.
Q194 The Chair: Welcome to today’s meeting. This is the 17th oral evidence session as part of the committee’s inquiry into childhood vaccination rates in England. Thank you to Caroline Temmink and Ian Perrin for attending as our witnesses today.
The session is open to the public. It will be broadcast live and subsequently accessible on the parliamentary website. A verbatim transcript will be taken of the evidence and that will also be published on the parliamentary website. A few days after this session, our witnesses will be sent a copy of the transcript to check for accuracy and, if there are any changes that need to be made, I would be most grateful if you could advise us of those corrections as quickly as possible. Also, if after this session you wish to clarify or amplify anything or send us additional material, we would be very grateful to receive it. When I ask the first question, I would be grateful if each of you would just briefly introduce yourselves and your role in your organisation, if I may. Thank you very much.
The first question is: how much progress has been made against the 2023 NHS vaccination strategy? How is progress measured and monitored, what dedicated funding is available for the strategy, and how does this compare to the costs saved by routine vaccination? We have heard that there is not any funding and that it only got through on a cost-equal basis. We have also heard, from somebody who tried to do it, that it is very difficult to say how cost-effective the core vaccination programme is. You may be able to enlighten us. You may know more than we have been able to find out up to this point. Perhaps we could start with you, Caroline.
Caroline Temmink: Good afternoon. I am the director for vaccination at NHS England, responsible for the delivery of vaccination services across England. We have made a huge amount of progress since we launched the vaccination strategy in December 2023. We are now in a position where every integrated care board has a dedicated vaccination lead who is responsible for delivering the vaccination strategy in their area. We have also made huge progress in digital capture and the digital infrastructure so a lot of that is building on the efforts during Covid-19, making sure that we can build that into our business-as-usual processes to take forward the innovation that we saw during the pandemic.
We also have dedicated funding in place to support outreach and inequalities work and we have been working a lot on widening the points of access for vaccination to make sure that we increase access for the public. That includes pilots in community pharmacies, working with health visitors and other innovative work on the ground.
There is not specific dedicated funding for the vaccination strategy. However, we do prioritise funding within our spending review envelope to make sure that all the elements of the vaccination strategy, particularly the digital elements, which are the most costly, are prioritised and affordable within our envelope.
In terms of whether that is good value against the saving for the benefits of vaccination, we obviously go through the spending review process and that is where funding is allocated to us as NHS England. Then we, working with our regional teams as commissioners, make sure we prioritise that funding as we see best and as commissioners see for their local populations.
The Chair: Thank you. Can we go to you, Mr Perrin?
Ian Perrin: Thank you. I am the assistant director in the integrated care boards network at the NHS Alliance. We are a membership body so I represent all 42 integrated care boards, look at them on a range of issues and this is one that we have been discussing with our members in recent times.
Where I would come in and start is that absolutely progress is being made against the strategy. Our members have been preparing for the delegation of vaccination responsibilities to integrated care boards since the strategy was published, something that they have expected for some time so they been working towards that. As Caroline set out, various things are in place to take that forward.
One thing worth highlighting, of course, is the context of the NHS reforms that are in place at the moment and the staff reductions that ICBs are undergoing. It is an important factor. I think what our members would say is that it is not something that should further delay the delegation of responsibility to integrated care boards, but they do need the kind of requisite support and resource to be able to fulfil the strategy effectively and sufficiently. That process is still ongoing. They have not quite completed their restructures, but they do expect to have done that before the next financial year and should be set up appropriately to be delivering successful vaccination services.
Q195 The Chair: Thank you. Can I just come back to you, Caroline? You rightly said that there is no additional funding for the vaccination strategy, but that you deploy a certain amount of NHS England’s funding to that. Given that the problems with coverage of the core vaccination programme have been going down over recent years, and given that the outreach always costs a lot more, has that proportion that has been allocated from your funding been going up over recent years to match the need?
Caroline Temmink: We do have an element of dedicated funding for outreach. For this spending review period, that is £13 million a year. It is difficult to compare it to previously because there was funding during the pandemic and obviously that was not a real-time comparison. Previous to that, there was nothing specific for outreach. However, the funding that was received by regional commissioners, they would use that funding and prioritise some of that on outreach. It is difficult, therefore, for us to say and to track that spending over time. However, we are in a position where we have confirmed that there are allocations for the next three years to cover some element of outreach, and it is up to commissioners if they want to top that up with some of their other funding as well.
The Chair: So they would be able to do that, would they?
Caroline Temmink: Yes.
Q196 The Chair: I see, okay. I want to ask now about consistency of message. The 2023 NHS vaccination strategy says that core settings should not be the only place to get vaccinated, and yet they also say that the offer should be at a consistent setting. At the same time, UK HSA, on quality criteria, says that increasing the number of providers does not necessarily automatically result in increased uptake.
It does not show a lot of confidence in the various outreach initiatives that indeed try to deliver vaccinations in other places, in the home, in pharmacies, in health hubs and various other places, does it really? How consistent would you say the message is for commissioners and providers?
Caroline Temmink: I think we are very clear on the message. We have done a lot of work recently on what we call our commissioning and contracting framework, which builds on the message from the vaccination strategy that the majority of vaccinations should be delivered through the core offer, so general practice for preschool vaccinations and in school for school-age vaccinations. We know that that is well understood by people, and that should be the place where the majority of people go. It does cost more money, in many cases, to deliver the outreach work, and UK HSA is correct that just putting in huge amounts more access will not necessarily drive uptake. We are clear, therefore, that the core offer has to be supplemented by additional points of access and outreach, but that must be developed locally based on what is right for the population. It is not a blanket case of we will put outreach everywhere; it needs to be targeted based on that local population and local knowledge from the commissioner in terms of what will work for that population. I think we are consistent, it is just that we need to make sure that the areas of outreach are well targeted and thought through in terms of how they are offered.
The Chair: From the point of view of the commissioners and providers, Mr Perrin?
Ian Perrin: Yes indeed, I think our members would say two things. I have spoken to a few over the last couple of weeks about this issue, and I think they would say that it does not feel particularly joined up at a national level, that it could be a bit clearer, and I think there are a few ways in which that could happen. One thing that has been highlighted to me is that sometimes the language used by UK HSA and NHS England and the Department for Health can be quite different, and that being really explicit about what we are talking about and the language that is used would be helpful. I have heard quite a lot about how it could be improved, so I am really happy to take that up outside of the committee.
Separately, I think there is sometimes a bit of a disparity between the message and the reality on the ground. A good example of that would be that yes, looking at multiple different settings for the delivery of vaccine services is a helpful thing to see where vaccines can be delivered most effectively. I have heard from integrated care boards that in some instances they request NHS England to look at different settings where they think they will be delivered more effectively, and at times have been told no, it must be in the core settings that are set out in the specification as described nationally. I think what our members would say is that what is equally as important is the autonomy to make the best decisions for their populations locally in order to deliver the most effective vaccine services for those communities that are not taking up vaccines.
The Chair: Thank you. Baroness Andrews would like to come in.
Baroness Andrews: Thank you very much. This is a question to Mr Perrin based on his first answer. When you were describing, Ian, the preparation that your members are making for delegation, you said basically that you did not think that there need be further delay, but that you did need requisite support. Could you expand on that a little, particularly on what constitutes requisite support and what will happen if you do not get it?
Ian Perrin: Yes. Our members are working towards delegation of the responsibility for vaccine commissioning services. What has happened over the last year is that through a document called the Model ICB Blueprint, different responsibilities and expectations about what ICBs would be doing in the future was set out. At that time, there were 18 different responsibilities, much broader than relating to vaccine services, which would be explored for transfer away from integrated care boards. Since then, 14 of the 18 have been described as now going to be remaining with integrated care boards in the future. When you speak to our members, they say that a year ago, X, Y, and Z might have been moved out of integrated care boards, but in reality, we have only moved one thing out, and we had three different responsibilities come in, at the same time as reducing their workforce significantly, up to 60%, 65% in some areas.
What I would be saying is that they should absolutely be responsible for the commissioning of services locally. They understand their populations and communities better than the national teams can because of the scalability and the relationships that they have in place, but there does need to be a conversation about what is the appropriate resourcing to have across the board because it is currently fixed. It does not matter how many services they have, the envelope for staffing all of that is fixed so there needs to be some pragmatism about how to approach that and to make sure that they are not being set up to fail.
Q197 Baroness Neuberger: Can I follow up with you, Ian, because, in a sense, you have answered bits of this question? We have been told by some of our witnesses that the NHS reforms present some significant risks to leadership and accountability on childhood vaccinations. I suppose what we want to know—and perhaps coming to you first, but then going to Caroline—what are NHS England and the ICBs doing to mitigate those risks and to realise the benefits of the new system in order to ensure leadership and accountability at the local, regional and national levels? You have already made several points on that, but I just want to add one supplementary to that before you answer. How will ICBs be judged on their success in improving vaccination coverage and reducing inequalities, given what you have said about the responsibilities they have and the lack of staffing?
Ian Perrin: If I can start with the latter part of the question, I think the part on inequalities is really interesting. Over the last year, the role for integrated care boards has shifted in national policy. ICBs are being asked to become strategic commissioners, and what that means is stepping back from the operational delivery in order to have an oversight of a population, to have better infrastructure for analysing data and looking at data, and then making commissioning decisions based on understanding of their populations and their needs. I think there is a real opportunity there, particularly with vaccine services and childhood vaccination, to look at the data and make smarter commissioning decisions about how money and resources are being used, particularly in a climate where the resources that are available to NHS services are diminishing. It is harder and harder to get the best impact that you can, based on population needs, with fewer resources, There is an opportunity there to do that, but I think the point I made earlier about the capacity and the responsibilities that integrated care boards have is a factor that needs to be addressed in order for them to be able to do that appropriately.
As I have mentioned, some of the functions that are staying with integrated care boards do have a more operational element to them, and so there is a bit of a disparity between what is being described nationally and what it feels like on the ground. I think our members are really up for the discussion about how to get this right in order to support and deliver better services locally.
If I could add one point to that, I think that what is really important to this is the connection between integrated care boards and local communities. You are seeing changing boundaries and mergers at the moment and mergers. We are shrinking from 42 integrated care boards to 25 and that poses greater scale and population coverage for them. The infrastructure to link to local organisations—the voluntary sector and charities that often understand their communities much better than ICBs or national bodies do—is a really important part of making sure that that is really successful and they have been working on making sure that they have the right infrastructure in place as this ongoing change has been evolving over the last couple of years.
Baroness Neuberger: Your point just then was going to be my second supplementary, which is about witnesses saying that ICBs now have too large a footprint to respond to local needs and the question really is how that is going to be mitigated. I am going to come to Caroline in a minute but before that, can you say first about how ICBs are going to be judged, or indeed judge themselves, on their success around childhood vaccinations? Can you also say something about mitigation of this emerging of ICBs and, if you like, the tightening of staff so therefore fewer people to be out in the local community? Then I will come to Caroline.
Ian Perrin: On how they are going to be judged, ICBs often look to what is described as the oversight framework from NHS England, which sets out the metrics for how they are going to be judged and the planning guidance that is published every year. There are aspects within those documents that talk about vaccination rates and vaccination services and the delegation so ICBs will be looking to that. It is up to NHS England to work with integrated care boards to make sure that their local strategies and plans do reflect the importance of this agenda. I think our members would say that it beneficial that the national team and national organisations are prioritising this, have a strategy in place and have the current campaign to make this a priority agenda. That is beneficial for integrated care boards because obviously the engagement over vaccines is a really important part of the process.
In terms of mitigation, I think ICBs have seen this coming. It has been on the agenda for a couple of years now. The delegation has been postponed multiple times so there is lots of infrastructure and work that Caroline has described and our members have been working through to make sure that they have the right governance processes in place, the requisite resourcing and the plans in place to be doing this.
I would come back to the point I made about the autonomy to make the best decisions for their local populations. There is a remaining question—the delegation of responsibility happens but are they truly free to design services and specifications in such a way that really deliver what their local populations need?
Baroness Neuberger: Thank you very much. Caroline, on the same point but from NHS England’s point of view, what is NHS England going to do to mitigate the risks of the change of system and to realise some real benefits of devolving to ICBs?
Caroline Temmink: We are still confident that delegation to ICBs is the right thing to do. We set that out in our vaccination strategy, so before the reforms were proposed, and our regional teams are working hard with ICBs at the moment to design what that will look like on the ground and also looking at what some of the gaps might be in any knowledge or skills that are required. We are working at the moment on a development programme to identify if there are gaps in knowledge and we need to do some upskilling but there will also be a safe-transfer checklist to make sure that we do not lose anything in the process. Obviously some of this is subject to HR and legal process and the passage of the Bill but a lot of the resource that is working on commissioning at the moment will transfer to ICBs to support that process, particularly the expertise, the screening and immunisation teams, who are the public health experts around vaccination, who do have local knowledge and will work with the ICBs going forward making sure that those vaccination services continue to be safe.
In terms of monitoring, we will work through tools such as the NHS outcome framework to make sure that there are metrics in there and we do anticipate, subject to the passage of the Bill, that these services will still be delegated so there will be an expectation from the Secretary of State around uptake and expectations of the programmes and that will continue to be set out.
Baroness Neuberger: What do you feel about setting up a local immunisation co-ordinator role, Caroline from NHS England’s point of view and then Ian from the ICBs.
Caroline Temmink: I think we need to be clear about what we mean by a local immunisation co-ordinator because I think it is often talked about in lots of different terms. We do have a number of roles already. I have already mentioned that ICBs have lead directors and as part of the GP contract, it is a requirement for each practice to have an identified lead vaccination to make sure that they are looking at their vaccination uptake in a practice. Also, many of our teams in the screening and immunisation teams will take a role in looking at that.
There is definitely something we can do about bringing that all together and making it cohesive to make sure we are clear about the different roles in the system but I think those roles do exist. We could go a bit further in terms of setting out exactly who does what.
Baroness Neuberger: When you have got a bit clearer about that do you think you could send us a map?
Caroline Temmink: I would be happy to.
Baroness Neuberger: Thank you very much indeed. Ian, on that point?
Ian Perrin: Similarly to Caroline, I would say the nature of local immunisation co-ordinator role depends exactly on what we mean about what that role will fulfil. With that caveat, I would say it would be welcome. and also that it would be really important that the role works across the NHS—also local government, with public health teams absolutely crucial in this, different settings, schools, education, and so on—to make sure that we are making the absolute most of what is available and the services that are out there to make those connections. When I speak to people locally they say that what they want to do more of over time is make every contact count, any opportunity to engage with public services and how are we using that to push for vaccination, particularly among communities that are not taking up vaccination services.
Q198 The Chair: Could I clarify something? We have a director responsible for immunisation at ICB level. We have people in GP practices, a named lead for vaccination. What is there in between currently and what do you think there should be in between because there is a very long distance between a GP practice and an ICB board? Can we have that clarified please?
Caroline Temmink: It varies in different areas so I do not think there is one model at the moment.
We do have at the moment at regional level screening and immunisation leads who sit as part of a team who are experts around vaccination and who sit with the commissioners. We also have people sitting in the child health information services teams who do the chasing. Again, it depends slightly on what we mean by the co-ordinator role but I am happy to write back with a bit more detail about how that joins up.
Ian Perrin: I would add that in local systems, some areas have what they call place-based partnerships, which are local committees to co-ordinate different public services in each area. Often, when I speak to members, they say that is the interface between hyper-local services, say a GP practice sort of footprint—versus the integrated care board and often is the best place for planning across services at a local level but also getting a bit more scalability across their geography to iron out where there is variation in performance and so on. That can often be quite a useful mechanism for that interface.
The Chair: We have directors of public health and we have primary care networks. Am I right in thinking that not every GP practice has to be part of a primary care network or do they all have to be part of one of those?
Caroline Temmink: That is correct; they do not have to be part of a primary care network but the majority are. Only a very small number are not.
The Chair: Right, okay, thank you. Can we move to Baroness Freeman please?
Q199 Baroness Freeman of Steventon: Thank you very much. We know how important it is for parents to be able to have a conversation with a healthcare practitioner about vaccinations before consenting and yet, according to UK HSA figures, only 45% of healthcare practitioners in the NHS have had the most recent flu vaccine. What have NHS England and the ICBs done to investigate why that vaccination level is so low among healthcare workers, how are you both looking at training for healthcare practitioners in how to have conversations about the information around vaccines and how are future training and updates to that training going to be commissioned, funded and organised? Perhaps, Caroline, you would like to go first?
Caroline Temmink: Can I take your second question first, if that is okay?
In terms of vaccination training, setting up the national standards is the responsibility of UK HSA and for providers to make sure that their staff are appropriately trained but we are continuing to work with them on making sure that is a more consistent model across vaccination.
As NHS England, we have done a lot of work recently about vaccination confidence training. We now have a number of learning assets available on the e-learning for health platform and also on our NHS England futures platform, that both employers and employees can use to support meeting standards on vaccinations, particularly in topics such as motivational interviewing as well as the technical administration of vaccinations. Working with UK HAS, we are trying to put information out there around confidence for staff to speak with parents about vaccinations.
Baroness Freeman of Steventon: Are those training courses compulsory and who checks who has done them?
Caroline Temmink: The technical aspects are compulsory, they are a requirement. Topics such as motivational interviewing are not compulsory but we are trying to encourage providers, particularly where they have a responsibility to drive uptake, to use these tools as well.
Baroness Freeman of Steventon: Do you know what proportion of people have done them?
Caroline Temmink: I do not, I am afraid, no.
Regarding the healthcare worker flu uptake, we are aware that flu vaccination uptake for healthcare workers has dropped, although we did see an increase in the winter just gone compared to a drop in the last few winters. We see a number of reasons for the drop. There is still some reluctance following vaccination as a condition of deployment that took place during Covid-19. That has had a particular impact on flu vaccinations with staff still reluctant to come forward. Some staff do not feel that they are at risk personally from flu, so that is a factor, but also staff are just incredibly busy and making sure that the offer is available to them at a convenient time alongside a busy schedule has been a bit of a challenge so that is something we have focused on. We asked trusts to do this last winter and we are doing the same for this winter coming, particularly having the flu vaccination very prominent in the trust, having senior leaders in trusts talking about it, making sure they are promoting it and the importance for staff and patients in terms of protecting both themselves and their patients, but also looking at some of the most successful trusts who have far higher uptake and sharing learning around what they are doing. Some of that is about access, making sure, in the same way that we have to think for the public, that clinics for staff are convenient around shift patterns and in convenient locations. We have also seen that peer vaccinators have been incredibly successful in driving uptake. We are continuing to focus this year. Flu has some slightly different challenges to it but you are right that we do need to make sure our staff are confident in speaking about vaccinations and are up to date with their own vaccinations.
Baroness Freeman of Steventon: Do you feel it is an access rather than hesitancy issue with health care workers?
Caroline Temmink: Not hesitancy in the sense of nervousness about the vaccination; that is not what we are hearing. It is more around it not being top priority for them.
Ian Perrin: I would reiterate what Caroline said. We often here that time capacity and pressure is the main driver, rather than necessarily an explicit decision not to get vaccinated. Also, in terms of what works, we hear that having a named executive lead to oversee staff vaccination often drives better uptake and to Caroline’s point about peer vaccinators , we hear all the time that being vaccinated by somebody that you know and trust in your workplace really drives better outcomes.
Baroness Freeman of Steventon: It is very much the same with the public.
Ian Perrin: Indeed.
Baroness Freeman of Steventon: What about training? How do you check within an ICB that everybody has access to the training and what is compulsory?
Ian Perrin: It is not really our organisation’s role to be checking whether our members are doing that. We are a membership body that is the voice of our system so I do not want to inadvertently speak on that topic.
The Chair: I have two supplementary questions on this. Perhaps we can have both of them and then you can reply. Baroness Cass and then Baroness Neuberger.
Baroness Cass: This just a comment before I come to my question. When I was working across the road at Tommy’s, the chief nurse stood in the entrance lobby of the hospital with a flu vaccination needle—and she was a small lady but boy you had to be a very brave person to get past her so that was very effective.
Q200 Baroness Cass: My question is to Caroline about e-learning for health resources. Does that mean that you are discouraging existing individually-taught programmes because I just passed you some correspondence about a long-standing education programme by quite senior individuals that has now been stopped?
The Chair: We will have Baroness Neuberger’s question now and then we will come back to you, Baroness Cass.
Q201 Baroness Neuberger: Yes it is a somewhat similar comment, in that I chair—and I declare an interest, Chair—UCLH and Whittington Health, where we have done the same, had a very tough and extremely scary chief nurse standing in the entrance or whatever and some very senior people but we are still seeing quite considerable reluctance so I think that just the experience that I have had would suggest that there is an element of reluctance among healthcare staff as well as it being too busy, long shifts and so on and I wonder if you would comment on the reluctance point because you must be picking some of that up.
Caroline Temmink: On the first point, we are definitely not prioritising e-learning over more traditional learning types, but we do also know that some people learn in different ways. Some of this is about being able to spread the learning more efficiently. E-learning is easier for us in terms of doing it once and that can be accessed by multiple people. Particularly for the core standards around administration of vaccines, it is incredibly important that that is still taught. We are supportive of lots of different methods of training.
I do think that there is reluctance, and some of what we have heard is around the Covid approach as well. A lot of the feedback we have had is that that vaccination as a condition of deployment has had a big impact. Workforce interests are made up of local populations, so there is an element of the challenges you see in a local population being potentially repeated in the local workforce as well.
The Chair: I noted you said that the technical side of vaccination training is compulsory but the way to have empathetic conversations with patients is not. What are the barriers to making sure that that training is also compulsory?
Caroline Temmink: That might be a question for UKHSA because it sets the core standards for training and requirements.
The Chair: We will ask them. Thank you. Is there any comment from you on that, Mr Perrin?
Ian Perrin: I have nothing to add.
Q202 Baroness Ritchie of Downpatrick: You are both very welcome. Pressures on primary health services have grown over the past decade at the same time as childhood vaccination rates have fallen. One study found that between 2013 and 2023 the number of GP practices in England fell by 20%, while the average practice list increased by 40%. In view of that, witnesses have also told us that funding for core primary care and school-aged immunisation services is often not proportionate to need. Therefore, how do NHS England and ICBs support GPs and SAIS to help reduce inequalities in uptake? I have a further supplementary, but I will come to Caroline first.
Caroline Temmink: Our funding is allocated to commissioners as a block across a number of services, and it is then up to them as to how they prioritise that. They make those decisions locally and that will become the responsibility of ICBs in April 2027. However, we do consult professional bodies on the pricing for primary care vaccinations and the pricing for our school-age immunisation services. That goes through a local procurement process and that is how the funding is agreed and set for those services.
We have tried some different things. For 2025-26, there was an increase in the item of service payments that GPs receive, and we are waiting for the outcome of the evaluation. That was increased by £2 per vaccination, so from £10.06 to £12.06. We are waiting to see if that has had an impact. We have also made some changes this year to QOF that we hope will make an impact, and we will be evaluating that, too. We have also seen that regional teams do supplement this funding in their local outreach and other services. I will pause there.
Ian Perrin: I would add that our members think that the resourcing question is a massive part of this. What they would add is that it is not always just about the volume of funding that is provided, but about planning cycles. They want to plan over a longer term, three to five-year cycles, in order to focus on some of the bigger, more strategic changes that they want to make in their local systems. Quite often what does happen is that small pots of funding for inequalities, for example, become available. I have spoken to someone who said that with something called the access and inequalities fund they can bid for funding, often at the level of £100,000 or £200,000. The process happens over the summer, and then they find out if they are successful around January time and are told, “Please deliver something for us by the end of March”. They often find that what they want to be doing is planning over much longer timeframes to be doing something more exciting that will likely deliver better change.
On the funding question, I think that our members would start with trying to work towards longer planning cycles. I know it is something that national teams have described and want to be doing, but our members would say that would be a top priority for change in this area.
Baroness Ritchie of Downpatrick: Thank you. As a supplementary question for Caroline, some NHS England contracts for school-age vaccination services include dedicated funding to help reduce those inequalities, many of which we have heard about over all our sessions. Therefore, what is NHS England doing to ensure that all contracts support sustainable action to reduce those inequalities?
Caroline Temmink: We have seen that some of our regional teams, when they have reprocured their contracts more recently, have developed some quite innovative funding models, moving away from the historic block contract, which does not incentivise an increase in uptake, and they have been very successful. They have had elements of the contract and the funding that are particularly focussed on health inequalities.
We are sharing a lot of that learning. Different regions will be on a different contract cycle, so their ability to reprocure and change that contract is limited until that comes up for renewal. However, we are sharing that learning and what has worked well to make sure when it does they can move into a similar contract. We are also updating our contract specification, because the core specification is set by us nationally and then added to locally, and making sure that we are strengthening the elements around health inequalities.
The Chair: Thank you. We have heard from some SAIS contractors who do some very good work. I think that the phrase used was, “We feel ourselves very lucky that our contract gives us the opportunity to do all the things that we need to do”, but it sounds as if they are not all like that.
Caroline Temmink: Not at the moment, because often these contracts are let between five and seven years, so it will depend on where they are in that procurement cycle. Lots of our regional teams and ICBs subsequently will be looking to shift more to that model when the time for procurement comes up.
The Chair: Let us hope that happens. Thank you. Ian, could I ask you about this idea of bidding for a lot of money and then getting it or not getting it and then having to put it in place very quickly? How much time do you think people spend bidding for money that they do not get?
Ian Perrin: A lot, yes. It happens across the board, not just in vaccinations. You understand why there are processes in place to make sure that the funding that you are bidding for is doing something meaningful and impactful, but it is a process that is laborious and complicated. Often our members would say the reward does not always make sense in the context of the time and energy that is put in.
The Chair: Lots of boxes to tick as well, I suppose.
Ian Perrin: Yes, absolutely.
Q203 Lord Dholakia: Can I ask you about NHS England commissioning and funding vaccination outreach and community engagement, typically short term? I wanted to find out what support and incentives there will be for the ICBs to prioritise, commission and fund sustainable evidence-based research.
Caroline Temmink: We recognise that direct commissioning budgets has been an issue over the last few years in terms of what Ian has described about bidding for funding short term. Just before Christmas, so in December, we did publish the direct commissioning budgets for the next three years, so that is the revenue allocations. Then it is up to the commission. They have discretion as to how they use that to deliver vaccination and screening services. We have worked for the period of this spending review to make that clearer, to set the expectations so that people can plan long term.
Regions then come back and tell us how they intend to use that funding, and they will be working with their ICBs on that as well. As part of that, it did include £13 million for the next three years, which is to support the access and improvement fund work that is happening out there. Regions can obviously supplement that with other funding as well for uptake improvement initiatives. We hope that that will go some way to giving a longer period of time so that people can plan and commission not just short-term projects but multi-year projects as well.
The Chair: Ian, do you have anything to add on that?
Ian Perrin: The only thing that I would add is that Caroline touched on one of the core issues that our members would raise, which is the interface between regions and integrated care boards. The question about the operating model and who does what I would say is one of the top three messages that I hear from our members: what are the responsibilities of different parts of the system? Often quite a lot of time and energy is spent on the interface between these different parts of the system. I think that our members would say that they want to crack on with the job of delivering successful services, and a clearer model for who does what and what the interface is between region, integrated care board and local services would be a welcome development.
The Chair: It strikes me that in that situation it very much helps if you know who to go to. Is there a danger that you will not know who to go to in future if there is lack of clarity as to who does what?
Ian Perrin: Do you mean if you are an integrated care board?
The Chair: Yes.
Ian Perrin: Yes, I think that is right. On the point I made about autonomy, our members say that they do not want to always be looking upwards for permission to go and do the thing they know will have impact. Sometimes it takes three months, six months or longer to get the right structures in place to go and do that. I think that the question is where things go wrong making sure that there is the support in place from national teams to support integrated care boards to make sure that things do not go wrong.
The Chair: Did you want to add something, Caroline?
Caroline Temmink: I think that is, again, part of the benefit of delegation in April 2027. It should take out some of that duplication and some of that process. ICBs will have that more direct control because it will be their funding allocation from next year.
Q204 Baroness Wyld: We have heard that for some vaccination programmes individual timely data is now available, and we have heard some examples. From your perspective, could you tell us how this has changed how services are planned and delivered? As a supplementary, what is being done to make such data available for all routine childhood vaccination programmes? Could you comment on how soon it might be available and the impact that would have?
Caroline Temmink: We have made positive steps in making that timely data available, and it has been incredibly helpful for our commissioners and for providers themselves as well to have access to that data, not just the timeliness, but the granularity as well and their ability to drill into it to understand who has and has not been vaccinated. From a commissioner perspective, particularly for things like time-limited seasonal programmes like the flu programme, it does allow adjustments to be made during the actual season in terms of thinking about areas where uptake might be behind where we would want it to be and therefore they need to change their approach. It is also about providers being able to think about who else they need to invite to make sure that they have followed up. I think that it is a real strength that going forward individuals will be able to see their vaccination record in the NHS app and understand what they are eligible for and what vaccinations they have had.
There is some work. This will be very much a fixed forward approach for us. Unfortunately, there are real challenges with some of the historic data, particularly in GP records. It is not all coded. Some of it is manual. It does not necessarily flow through in a neat way. While we will look at trying to capture some of that information, we can only be really confident in the data going forward from the point that we have put the fix in place.
We are working to try to do this across the period of this year, but it involves us working with GP IT systems and with child health information systems, and we want to make sure that we have the data robust and accurate. We need to make sure we are following all the information governance processes as well and we have the correct legal basis on which to process the data and flow that. We are working, I hope, across the course of this financial year to get data flowing for all programmes, but we have to do some of this programme by programme while the infrastructure is there. We still need to make sure it is right because each programme has slightly different challenges in some of the coding and the way that they have historically been set up.
Ian Perrin: I would just add that I concur with what Caroline has described. When I mentioned earlier that role that integrated care boards are moving to around strategic commissioning, our members always say that the commissioning you do is only as good as the data that you have to inform it. How do you know if it will be successful if you do not know what it is you are commissioning for? You also need the data to be able to measure the impact of the services that you are commissioning. It is crucial, I totally agree.
The only other thing that I would add to that is that our members are doing interesting things in joining up NHS datasets with, for example, local government datasets to get a much broader picture of populations’ interface with different public services, not just NHS services. That is an area where a lot more interesting work can be done to make sure you are engaging with communities in the right way and delivering successful services.
The Chair: At the patient end of information, what is being done to take account of those people who are digitally excluded?
Caroline Temmink: In terms of bookings, we do make sure that we always have alternative methods, so not everything is through the app online. Ultimately, the GP is still the core holder of the data and the single patient record going forward, so people will be able to access their records if they have any queries through their general practice as well.
Ian Perrin: The only thing that I would add is that digital exclusion is a massive part of this. Our members often highlight not to forget about health literacy as well. Understanding services and understanding what is happening with your data and all that stuff is crucial to this.
Q205 Baroness Andrews: Thank you very much. This is the last question and it is really a summary question. You have both been very positive and are clearly very determined to make these new systems work and integrate well. However, we have had fairly consistent evidence from all our witnesses, which in fact backed up the evidence to the Minister from the Commons Health and Social Care Committee, that there are outstanding issues that need attention. Our question is: how do we as a committee now prioritise our recommendations so that they have real impact? The thing that we have come across is the need for clearer responsibility and accountability. Ian, you spent a fair bit of time a minute ago talking about the need for a clearer model, one that properly integrated the ICB with local services and so on. Then you talked about funding for core and outreach services, matching capacity and need, and better training and development. We have had some additional points as well to do with the need for open dialogue, especially with communities that are reluctant and may be a bit resistant to the notion of vaccination and the whole challenge of integrating it into public health. If I were to ask each of you for your three top priorities that you would want to see as our top priorities in our report, Caroline, what would you say?
Caroline Temmink: My first one would be the continued message around the importance of vaccination and the need to put that alongside some of the other interventions in the health service, so to put the conversations on an equal footing in the same way that we do with elective targets, A&E and other things that keep the health service going. I think that it is that continued prioritisation there and vaccination really being at the forefront of thinking.
Secondly, it is encouraging and embedding vaccination in other services. As we think about the design of any new service, it is thinking about how vaccination can be part of that. In family hubs, for example, and neighbourhood health, make sure that vaccination is integrated into all those approaches.
It is very clear that there is no magic bullet in turning around uptake, otherwise we would have done it. I am confident that we have lots of different things in play. It is the sustainability of some of that. We need to give some of this time to bed in so that we can build on it and allow some of the things we are doing to continue, supporting some of those changes that we are already making to continue. The longevity of what we are already doing is my third one.
Baroness Andrews: Can I ask you something about each of those? That is a wholly preventative message. Would you like to see a campaign, for example, around vaccination to lift that message? On the notion of embedding it within services, do you think that needs additional agency or do you think that there is a momentum behind it that will take it with it? On the third point, recognising that it takes time, we have talked a lot this afternoon about the reform that is going on at the same time. Are you concerned that continuity might be broken in that sense?
Caroline Temmink: To take your third point first, I am not too concerned about that, but we have invested a lot in these systems and in the approach and I think that it is important that we make sure we give that time to bed in.
On the overall narrative, we do have public health campaigns and messaging, but I think that continued prominence of vaccination is the key and the importance. Those of us who are interested know, but normalise the conversation about vaccination so it is not almost seen as something we are afraid of and shy away from in case people do not agree with our point of view. It is really about that normalisation of vaccination and prominence as well. As it is prevention, we do not always see the impact directly or straight away, although obviously with measles outbreaks, as we have seen recently, we do. Make sure that it does sit up there in the NHS’s top priorities, which it does at the moment, but continue to do that and have that messaging through all elements of our planning.
Baroness Andrews: Thank you very much. What about you, Ian?
Ian Perrin: I am supportive of the national prioritisation and messaging in campaigns and so on. For integrated care boards taking on the responsibility, my headline message would be that stability is important for integrated care boards. We have had a lot of change, and being able to plan over the long term would be helpful.
For me, there are three messages that sit under that. One is whether the autonomy to design services will follow the responsibility. Asking NHS England and the regional teams to make sure the integrated care boards have the freedom to do what they need to do for their local populations is crucial.
The second would be the point that I have highlighted before and Baroness Andrews mentioned, the financing, the funding, and long-term planning cycles, ending this habit of annual planning, pots of money that are available but short term and then you do not know whether it is happening next year and so on, going on to a more long-term footing.
Thirdly, it is the point about the clear operating model. I would just add to that that not only is it about who does what at each layer of the system and what their role and responsibility is that is critical to this, it is that point that we started with about national join-up, making sure all organisations at the national level are singing from the same hymn sheet and being clear about what they are saying and asking for from local organisations.
Baroness Andrews: Those points that are operational in terms of autonomy and funding and a clear operating model, you could see them written across into the provision of vaccination as clear as daylight.
Ian Perrin: Absolutely, yes.
Baroness Andrews: Yes. That is what we deliver for you. You would be delivering what Caroline wants, in fact, by doing that through the ICBs.
Ian Perrin: Absolutely, yes.
Baroness Andrews: That is helpful. Thank you very much indeed.
Q206 The Chair: Thank you. Baroness Andrews said that was the last question, but we have all been extremely well disciplined, and thank you for that, which means we have another five minutes. I have a couple of questions that have occurred to me and it may be an opportunity for other members to think of anything that they want clarifying in the next five minutes.
I have two questions. Ian, do your members see it as part of their role to use their communications networks to send out positive messages to the public about the reason for and the effectiveness of vaccinations?
Ian Perrin: The short answer is yes, absolutely.
The Chair: A wonderful answer. Thank you very much. Do they do it?
Ian Perrin: They do it, yes. One thing that I think is important to highlight here is that with the NHS Modernisation Bill coming forward, there is provision there expected on the transfer of health watch functions, which is community engagement, into integrated care boards. What we are talking about with our members is what a different model for community engagement looks like and how you bring on these services and do them in a better, more comprehensive way. I do not think that anyone would say they are excellent at this. Sometimes you get patches of good practice, but across the country I think that there is lots to be learned and developed on how to do it better. Again, we have talked about functions moving into integrated care boards and making sure they have the resource to support and deliver those things successfully. For this community engagement function that is likely to move into integrated care boards pending the Bill, the same point stands.
The Chair: Thank you. There was a question earlier about who holds the ICBs to account. I think that the answer was the regional NHS England offices. My question is: when you get the reorganisation, if the Bill goes through as it is currently written, does that role go to the department?
Caroline Temmink: That will be the responsibility of the department. How it chooses to discharge that I think is being worked through at the moment, whether that will be a model through the department, regional teams or through a different method.
The Chair: What happens currently if it is felt that an ICB is not living up to the expectations that we have of it?
Caroline Temmink: At the moment it is our NHS England regional teams who are responsible, so still until April next year.
The Chair: What do they do?
Caroline Temmink: Generally, it starts off as a supportive conversation. We have a lot of insight nationally as well. Based on the data, we will work with our regional teams to make sure they generally are aware, making sure that we are looking at what the problem might be. We look for assurance through our regional teams that they have a plan to address this. That goes up as needed through the NHS performance management framework, so through the conversations with regional teams and regional directors.
The Chair: Do they have extra support for that?
Caroline Temmink: We will work with them. It is generally a supportive approach, so we will work to make sure that if there is anything else that they need, we work collaboratively to try to address the problem.
Q207 Baroness Browning: Could you just remind me whether you know now exactly the boundaries of the new ICBs?
Ian Perrin: I would say it is a complicated process.
Baroness Browning: That is what I thought.
Ian Perrin: There were 42 integrated care boards set up in the 2022 Health and Care Act. There were a series of mergers that came into effect from 1 April this year. There is currently an ongoing conversation between the centre, local integrated care boards and their local partners, in particular local authorities, about some potential mergers to take effect from 1 April next year. The current approach is for local integrated care boards to decide if they want to change their boundaries with their surrounding integrated care boards and with local authorities. There is a process that is ongoing for future boundary changes, the outcome of which has not been determined yet.
Baroness Browning: It sounds as though that is still in quite a state of flux until next April, when presumably they will be the determinants on which real decisions will be made.
Ian Perrin: Yes, correct. There are a number of integrated care boards that are currently clustering, which is working together with some shared arrangements. Some of those may be ones that go on to merge, but they are revisiting what the best local arrangements are for services locally.
The Chair: Thank you. Are there any further points of clarification from committee members since we have a couple of minutes? No. In that case, I want to thank you both very much indeed. We have had a very interesting session. I am bringing the session to a close now.
