Childhood Vaccinations Committee
Uncorrected oral evidence
Monday 29 June 2026
3.10 pm
Watch the meeting
Members present: Baroness Walmsley (The Chair); Baroness Andrews; Baroness Browning; Baroness Cass; Lord Dholakia; Baroness Freeman of Steventon; Baroness Hodgson of Abinger; Baroness Neuberger; Lord Randall of Uxbridge; Baroness Ritchie of Downpatrick; Baroness Wyld.
Evidence Session No. 18 Heard in Public Questions 208 - 223
Witnesses
Dr Mary Ramsay, Director, Public Health Programmes, UK Health Security Agency (UKHSA); Dr Julie Yates, Deputy Director for Immunisation Programmes, UK Health Security Agency (UKHSA).
USE OF THE TRANSCRIPT
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Dr Mary Ramsay and Dr Julie Yates.
Q208 The Chair: Welcome back to today’s meeting. This is the 18th oral evidence session as part of the committee’s inquiry into childhood vaccination rates in England. Thank you to Dr Mary Ramsay and Dr Julie Yates for attending.
The session is open to the public and it will be broadcast live and subsequently accessible via the parliamentary website. A verbatim transcript will be taken of the evidence and published on the parliamentary website. A few days after the session, our witnesses will be sent a copy of the transcript in case there is anything that needs to be corrected. Please advise us as soon as you can if there are any corrections to be made. If, after this evidence session, you wish to clarify anything or amplify any points or send us any additional material, that will be very welcome and please do submit it to us. Before you answer the first question, I would be most grateful if each of you would just introduce yourselves briefly and say what your role is in your organisation. Thank you.
Here is the first question. How much progress has been made against the UKHSA’s 2025 immunisation equity strategy and how is that progress measured? What is the relationship between the immunisation equity strategy and the 2023 NHS vaccination strategy? Perhaps you would like to go first, Julie.
Dr Julie Yates: I am deputy director for immunisation programmes within UKHSA. If I could possibly tip that question on its head a little bit, the UKHSA immunisation equity strategy is the second of our equity strategies. We published the first, which was then called an immunisation inequality strategy, in 2021. That went a little bit under the radar because we were in the middle of Covid, but a lot of work was done with our colleagues at local level and within NHS England. That included a health equity audit and a local action plan, which was a template that was used by many of the regions to develop their plans in relation to inequalities or reducing inequity in immunisation services and access. The NHS England vaccination strategy was then a strategy to optimise operational delivery. They are slightly different, but the vaccination strategy is intended to improve uptake and to support reducing inequity. That was published in 2023 and so brought in some of those elements of the 2021 strategy.
Now, two years on, we have been working together during that time and have revised the 2021 strategy, updated the terminology, and focused on different actions to build on what we did with the previous strategies, building on the data sources and renewing the health equity audit so that we are clear on the situation now. That published document has some useful data as well. Then we are looking at how we can use that experience of the previous few years to develop a more advanced strategy with some new objectives.
We have all been working together as part of that. They build on each other and so they are not mutually exclusive. Although the 2025 immunisation equity strategy is UKHSA badged, it is a tripartite document. We have been working with colleagues in the Department of Health and NHS England and wider stakeholders on developing that strategy. We are all working together on that.
The Chair: It is clear that it is a matter of one building on another and incorporating part at least of the previous one; is that right?
Dr Julie Yates: Absolutely.
The Chair: Do you feel as if you will in two years’ time need to do another one as things change?
Dr Julie Yates: As things change, in the same way that we have repeated the health equity audit, which helps us to identify whether things are improving or declining and where we can further target activity. Yes, these are dynamic strategies. They are not static. We anticipate revising and reviewing that in two or three years’ time again together and with colleagues in the new system as well.
The Chair: Mary, do you have anything to add to that?
Dr Mary Ramsay: It is definitely a joint piece of work and you definitely need to keep refreshing it. I cannot see any other way of doing it because, as the system changes, you will need to react to that.
The Chair: Are you satisfied now that you have clear and consistent messages going out to commissioners and providers?
Dr Julie Yates: We are. We are still working together on the metrics for performance managing that strategy and for understanding whether those activities are working or whether they need to be further tailored. That takes quite a lot of engagement across the system to ensure that they are aligned with other performance management systems that are there, for example, for the ICBs or for providers. We want to streamline that as much as possible and have buy-in from all the partners so that people have ownership of it and are then able to engage with delivering on those actions.
The Chair: It is a changing system. Does that present any difficulties for your strategy being implemented?
Dr Julie Yates: It does add to the challenge, but the key is that we continue to communicate across the tripartite. As people merge or those systems change or partners change out in the system, such as ICBs taking on the delegation and having more ownership of the services at a local level and the design of them, we need to shift some of our discussions and ensure that we engage all the right people as the new system emerges.
The Chair: Thank you. Can we go to Baroness Neuberger now, please?
Q209 Baroness Neuberger: Absolutely. Thank you and welcome to you both. I have a general question and then a specific one. How effective is public health system leadership and accountability for childhood vaccinations now and in view of what you have said about the shifting system? In the context of the NHS reforms, how could we strengthen national, regional and local leadership and accountability? I will come on to the supplementary.
Dr Mary Ramsay: I will kick off with that. I am the director of public health programmes in UKHSA.
This is an important point and in some ways we have a lot of good expert leadership in the system in the UK. We have one of the world-leading expert committees that advises on the programme we use and they are supported by experts at national level. My own team and I support them and a range of other experts who come in and help with that committee. That means we are able to make our policy public health-led and evidence-based. The NHS constitution also has this reinforcing thing that the Minister is obliged to take advice from the JCBI, which is an important point for keeping a programme expert and public health led. We are good at a national level.
That needs to translate down at every level. The programme is much more complex than it used to be. We do not vaccinate only children anymore. We vaccinate lots of different population groups. There are more vaccines. Some of those vaccines require multiple courses over many decades sometimes. It is important that the providers who offer those services are supported properly at a local level with experts at a local level as well.
Expertise is the key here. That expertise needs to be, first, networked together so that they can share good practice and so that that national-to-local two-way conversation happens to ensure that we provide a consistent, high-quality, safe service and one that is trusted by the public. That all hinges on having the right knowledge and evidence and access to people who can support providers who may be delivering occasional vaccines and who need that support. That is important and it would be important in the new system, regardless of where those experts sit, that they have sufficient independence, competence, capacity and leverage to be able to make all the different system players work together.
Baroness Neuberger: Will that happen?
Dr Mary Ramsay: I am hoping it will, and we are pushing hard for it. It does need to be recognised, and sometimes it is not. There is a danger, particularly with the Covid approach with mass campaigns, that it gets dumbed down a bit because immunisation is more complex than just giving one vaccine to a lot of people at one time. It is not just sticking needles in arms. It is talking to parents, it is talking to people, and all that work requires expertise.
Baroness Neuberger: I specifically asked—and it was deliberate—how we could strengthen all of that? Give us some examples of what we could do to make it better than it is now.
Dr Mary Ramsay: Training, which we will come on to later, needs to happen for frontline providers, but also for those experts who are supporting the system. They need to be trained and they need sufficient capacity. There needs to be a recognised position. Way back in the 1980s when we said that every area has have a district immunisation co-ordinator has got lost a bit with all the fragmentation in the system now. Having nominated individuals who have that leadership role and who are recognised as leaders locally is important. We could positively recommend that.
Baroness Neuberger: That needs strengthening. Okay. Dr Yates, do you want to say anything on that particular question first? Then I have a supplementary.
Dr Julie Yates: No, Mary said everything, but the strengthening of that and the links up and down the system are important.
Baroness Neuberger: Okay. This is to you in the first instance and then to Mary. Some of the people we are talking to have told us it is pretty unhelpful that UKHSA advises them against producing local communication materials responding to common and specific questions about vaccinations. I was going to ask you, wearing your UKHSA hat, whether there should be more local flexibility on how to meet national standards. That is a more generic point than just advice and communication. I would like to have Mary’s view after that, but could you talk about the UKHSA point of view particularly?
Dr Julie Yates: Do you mean more generally than resources?
Baroness Neuberger: No, if they want to be aware of local circumstances and local concerns about a specific vaccination, the advice is that they should not have different communications materials from the more nationally approved ones. Can you say something about that?
Dr Julie Yates: That is absolutely fine. I am not aware that UKHSA does say that. From our perspective, we would like to work with our colleagues at local and regional level. It is important that we understand what the communications will be so that they are accurate and effective. We can give quite a few examples of where we have worked closely with local areas that have wanted, for example, to develop local videos and local resources. We provide our national artwork and templates for them to amend as necessary.
Baroness Neuberger: We are hearing a bit about this. It would be helpful if you could go back and maybe send us material afterwards about examples of working with local organisations to produce local communications because we would like to know about that. We would like to be able to say that there can be local variation, provided one reaches a particular standard. Is that possible?
Dr Julie Yates: Yes, we can go back and provide you with those examples, absolutely.
Baroness Neuberger: Mary, do you have anything to add on that?
Dr Mary Ramsay: Yes. Communications is a broad topic. The information resources and our leaflets that we produce ourselves, which we translate and update and all those other things, are largely about making sure people get fully informed consent, which is important. It is important they get the right information, the pros and the cons, with balance.
Wherever possible, we try to tailor that for specific groups. Covid was a good example when we had people who were at higher risk and high-risk children versus low-risk children. We made sure that the leaflets that were supporting that consent process explained that because, for an individual healthy child, the risks were very low for them. We like to ensure those messages are correct. We make sure they are updated and we try to provide a range of accessible formats and languages. We are keen that our resources are used and that someone does not write their own. That is inefficient and it risks inconsistency.
On broader comms, which is when you are perhaps going out and trying to raise awareness in communities and bring people in, absolutely, we are happy for people to locally tailor that. Maybe it is that distinction.
Baroness Neuberger: It may be that, but we would like to find out some more from UKHSA. Certainly, none of us would disagree about reinventing the wheel and doing local comms that are exactly the same as national ones, but in specific either communities or areas people are asking specific questions and they are not necessarily covered in the national stuff. That is where we want to look. If you could give us some more information, it would be hugely helpful.
The Chair: What are the barriers? If local organisations feel that they need to tailor what you have sent out for their specific community, do they get the chance to talk to you about it?
Dr Mary Ramsay: Yes, I hope they would. That, again, comes back to this thing of having this network of people who are all working together on the same thing. Hopefully, most people know we exist and can come to us. Our leaflets, for example, are in HTML on the website. You can literally paste them and change them if you need to. There is no barrier to that.
We would like to think they would check with us. We have our own network but also, in UKHSA, we have comms officers who will work at a regional level and will know the local communications officers for the local authorities or for the NHS and, hopefully, would work together. Absolutely, we are happy to work with them, and also maybe to help them a bit because, when people ask difficult questions, it is difficult to know how to answer them. We have often done it ourselves before and can say, “This is a good way of framing this question with this community”, or, “Why not speak to someone in the north-east who has done this before?” I hope that we would see ourselves as part of that.
The Chair: If they tailored the information to their community and you picked up something that might appear to be ambiguous or incorrect or something, you could sort that out between the two of you?
Dr Mary Ramsay: Exactly. Of course, they can feed back to us. If they think something in our leaflet is causing an issue, we will change it. We have done that.
The Chair: Thank you. Did you want to come in, Baroness Cass? You were looking at me. I know Baroness Andrews does.
Baroness Cass: No, it is all right.
Q210 Baroness Andrews: Thank you very much, Chair. I want to pursue something with Mary. In one sentence, you brought together all the challenges, in a way, of what is different about our present situation. We have a more complex situation vis-a-vis structures, more people being vaccinated across the spectrum, more complex vaccines more often, and more expertise needed. Then, when Julia asked you about how to strengthen it, you mentioned training and frontline expertise in a recognised position, and you reflected on the loss of the district capacity.
We had evidence from the ICBs about their challenges in terms of capacity, loss of staff, loss of funding and additional responsibilities. Even with a commissioner based in the ICBs, can this task be developed and delivered by the ICBs, given the challenges that you have described?
Dr Mary Ramsay: I hope so. You heard from the last witness that it is a priority for ICBs. It is about expertise. The commissioners have their expertise in commissioning services and writing contracts and working with providers and all that other work, but you do need to have access to expertise. It is a clinical specialty. In the same way as it would be if you were trying to set up cancer services, you would talk to an oncologist. People should not see this as different just because it is immunisation. It needs not to be dumbed down. You should be able to access it.
A good cadre of expertise is out there, but we need to sustain it because it is not a recognised specialty in that way. Some of us at the end of our careers need to ensure people are coming through who can follow that forward. People may come in from different backgrounds. Some good GPs have taken an interest in immunisation and do good pieces of work. People who come in from paediatrics and so on. We can find a workforce and it needs to be used and recognised.
More resources in this area is always helpful, but one of the other speakers also mentioned sustainability being important. There is no point putting someone in place for a short period of time. We need a sustained system that has that expertise at the root of it.
Baroness Andrews: You seem to be saying something rather deeper than we might have heard before, which is that this business is an expert service and, therefore, talking about time and patience and understanding. Have we lost some of that then in recent years?
Dr Mary Ramsay: We have lost a recognition of it. There are lots of experts out there, but we do not recognise it as a specialty in itself, which we have probably missed. Certainly I am a member of the Faculty of Public Health and we are trying to strengthen that group.
The way that public health went in the last reorganisation potentially fragmented some of that expertise. That is a risk with every restructure. If someone works in a hospital as a doctor, they will work in a hospital after the restructuring. They will be in the same place. Public health tends to get pushed around and it is always a challenge, therefore, to try to keep those people as part of that system.
Baroness Andrews: That was interesting. Thank you so much.
The Chair: Thank you. Baroness Freeman next, and then Baroness Neuberger.
Q211 Baroness Freeman of Steventon: Thank you. On the communications point, I wondered whether your policy was to pre-empt misinformation or misunderstandings or whether you worried about the backfire effect and, therefore, tried to avoid things like the link between MMR and autism?
Dr Mary Ramsay: Yes, absolutely, we do have an approach, I would say, and that is evidence-based but also experience-based. I live through the MMR concerns. When you are working with a network where misinformation is being promulgated all the time, you can never address every single question because whatever question you try to address with a study, there will be another one, twisted, the next time for you to answer.
The evidence suggests that it is most important, certainly with public facing information, to reinforce the fact that immunisation is effective, safe and well-studied, and a consensus supports it. A consensus of health professionals supports it. That is the best message.
That does not mean that if an individual parent comes and asks a question about a specific thing, you should not try to answer that. You have to address that by making sure that the healthcare professionals themselves feel confident enough to say, “That is not real. That is not a true message. That does not make sense. This study has looked at it”, and all that information.
On the public facing thing, evidence shows that by putting myths out there, you increase their profile and you bring people who were not concerned into an area where they might become concerned. We do not want to encourage that.
Baroness Freeman of Steventon: Do you avoid that in your public-facing work?
Dr Mary Ramsay: In the public-facing stuff, yes, in the main.
Baroness Freeman of Steventon: Do you have anything to add on that?
Dr Julie Yates: The key for a lot of our communications is consistency and being consistent always on positive messages. That does not mean that we do not say that there are risks or potential side effects, for example, from vaccines. All our communications have to include that breadth of information for them to be effective. Sometimes those can be slightly watered down because people are a little bit anxious or concerned about having those discussions. That is where we need knowledgeable, confident, competent staff to be able to do that.
Q212 Baroness Neuberger: Can I come in at this point? Following up, Mary, on something you have said that may be quite important for us, you have talked about being in the Faculty of Public Health Medicine. For full disclosure, I am an honorary fellow of it. You have said that there is a group. One thing we are getting is that this is a changing area, things in public health keep moving around, it is all a bit complicated and so on.
Is there an argument for strengthening this voice and strengthening consistency, for strengthening that group within the faculty and for upping the game for those people who are professionally involved? It seems to me that there is something here about the professionals themselves having more strength and more voice that we have not heard much about before, but it is coming out now. I wonder whether either of you would like to comment on that.
Dr Mary Ramsay: Yes, we have resurrected it in the last few months for that reason, exactly. I completely agree with you. However, it is not just members of the faculty we want to help with this. We are happy to have other people helping. Yes, there is a case for that. Hearts and minds are a big thing in this area, much more so than in governance arrangements and contracts and specifications. It is important.
Baroness Neuberger: If your group has already come up with anything, it might be quite useful for us to see it, if that is okay.
Dr Julie Yates: The group is new. We had a launch event recently and we have terms of reference we can send you and the intentions of where we are going.
Baroness Neuberger: The intentions could be helpful. Thank you very much.
Q213 Baroness Cass: Can I follow on from that? This may be a reflection of my age, but the names I know in the field are all your age. A generation was invested there and became interested in this. As sometimes happens in specialties, there is a gap and then the next people are quite a bit younger. Are potential leaders in that middle age group coming through?
Dr Mary Ramsay: Yes. I have some good people in my team who are younger. I do agree with you. It has an ebb and flow a bit. Sometimes things that go wrong invigorate interest in the specialty.
The faculty itself does not have a clear way. How do you become someone who works in immunisation and public health? What is the training scheme? People who work in health protection have a clear training scheme. People who work in local authorities have a training scheme. They are well catered for. One reason we started this interest group was to try to make sure people at the start of their careers who wanted to become immunisation specialists had a path.
Baroness Cass: It was at one time about a third of what community paediatricians did until the last reorganisation.
Dr Mary Ramsay: Of course, it is not just a paediatric thing anymore. I realise this is about childhood vaccination rates but, yes, we need a wider workforce there.
Q214 The Chair: Before we move on, I will put you on the spot, I am afraid, and if you do not know the answer, perhaps you could write to us.
We had some written evidence from Public Health South Tees, who were not impressed by the consent letters and materials for school-based programmes being sent to parents, and decided to improve them. It was not just their idea, but they proved that they worked better because they found an increased uptake of 24.7 per cent in one school, and then that was replicated across other schools in the area. Yet they tell us that these are now being halted by UKHSA, which insists that national leaflets of 20-plus pages long, which go unread, are used instead. Surely, if something works in an area, you should not stand in the way of letting it be used.
Dr Mary Ramsay: I do not believe we are. We do try to encourage use of our leaflets and we have evaluated our leaflets and they do not necessarily go unread. They go unread because people do not get them. I do not believe there is a 20-page one for school-age immunisation either. We can go and investigate.
The Chair: I will ask you to come back to us on that. I know it is quite unfair to put you on the spot like that, and so please do write to us. Thank you. Can we move to Baroness Browning’s question, please?
Q215 Baroness Browning: Thank you very much. Keeping on the theme of consistency, how consistently do commissioners and healthcare providers follow UKHSA quality criteria for an effective immunisation programme and NICE guidelines for improving childhood vaccination uptake? I will ask Julie if you would start because you have some responsibility for the design and you are right at the heart of this.
Dr Julie Yates: Yes. Our responsibility is to develop and produce the guidance that can then be used to support and guide operational delivery. We do not have responsibility for how those are implemented and how those are taken up by those local areas. That can happen through the strengthening of the local expertise. The local screening and immunisation teams have responsibility in their areas to improve quality, improve uptake and reduce inequalities.
We have worked closely with our colleagues in NHS England on the development of their implementation frameworks. There are some good examples of areas that have implemented the NICE guidelines by undertaking, for example, an audit of their practice against the NICE guidelines. I can think of examples in the south-west, for example, which have done that and then created a plan for reducing the gaps in their compliance against those standards.
We do not have an assurance that those are being consistently implemented in all areas. There is some variation in that.
Baroness Browning: Could they be?
Dr Julie Yates: Personally, I think they should be. They form a good framework for an effective immunisation programme. That is why they are called quality standards for implementing an effective programme. They cover all the different areas that you would need or all actions you would need to have in place to ensure that your programmes are effective.
I suspect that in some areas that have had quite a lot of change in personnel, systems and structures, people may not be as aware of those guidelines as they may have been in the past. It is a challenge for us to ensure that they are and that we raise the awareness through our national clinical network and through other routes.
Baroness Browning: Do you know, taking a bird’s eye view of the whole of England, whether the clinical guidance is being followed consistently?
Dr Julie Yates: It is difficult to say that we do know. Those standards are applied inconsistently.
Baroness Browning: Does that worry you?
Dr Julie Yates: Yes.
Baroness Browning: Has anybody thought of doing something about it?
Dr Julie Yates: That is part of the work that we are doing or have been doing with NHS England on developing the performance frameworks and the accountabilities frameworks for, for example, the ICBs and working with our colleagues in NHS England, who are responsible for those local teams since they moved over to NHS England in 2021.
We do not have the levers from our own perspective. We are working on that hearts and minds and engaging with our colleagues in local areas and building those relationships to ensure that that happens. NHS England has responsibility for the assurance of provider activity and we work with them on advising those local teams in particular where issues are raised or where the quality lacks consistency. We cannot point to any overarching picture that would give us the full range of what is happening and how that is being implemented on the ground.
Baroness Browning: Thank you. Mary, do you want to add to that?
Dr Mary Ramsay: We have also talked to this national quality board in the NHS and things like that and about how we can try to embed some of this good work. It is largely hearts and minds. It is difficult to put all these things formally into contracts that. I know some good providers are out there and some good GPs who run a brilliant service and some good other providers, but it is difficult to assure ourselves when something is delivered so widely across the system that everybody is working to those standards.
Q216 Baroness Browning: It seems a theme has developed as we have taken evidence from various people on different aspects. That is that it is difficult, from a committee member’s point of view, to get a feel of who ultimately is responsible for certain things. When it comes to standards and quality control, I realise sometimes people back off because it starts to become bureaucratic and people do not want to or will not or cannot spend resources on a lot of extra data collection if it will not be used for a good purpose at the end of the day. We all understand, particularly within the NHS, why that needs to be streamlined but still keep everybody safe and the systems competent.
You heard the last session, session 17, and the speakers there when we were talking about ICBs. Does anything about the new structure of ICBs make you think that this will become improved or should there be a specific message to these newly constructed ICBs that would help raise these standards and make sure clinical guidance is followed?
Dr Julie Yates: There is an opportunity.
Baroness Browning: Who would do that? Would that be you?
Dr Julie Yates: It needs to be a combined effort of the various organisations that are involved. We have a responsibility for ensuring that those standards are there in the first place and developed, and then for ensuring that people are aware of them, and then providing expert advice and guidance on how they might implement them. It needs that partnership with the local public health expertise, which can then work with their own providers at local level and their own stakeholders with an understanding of the needs of those groups to ensure that those standards are applied to the services they are providing.
It needs that. It cannot just be done from national level. It needs to have that system and a feed up and down of public health expertise to support people in applying and complying with those standards.
Baroness Browning: Presumably, if some system of measuring these things was known at a national level, you could start to praise the people. You could have an annual dinner and give them an award or something, and then everybody else would then want to be top of the pops next year. I am only joking about that, but I am thinking of incentives that pick out where best practice is almost normalised, which is what we want. Then that gives you the opportunity to identify where more support and training is needed. That need not necessarily be bureaucratic to produce a system like that.
Dr Julie Yates: You also need the link between the regional, local and national public health expertise to be able to do that, to be able to have that oversight and understanding of who is providing good practice and who may need additional support.
Dr Mary Ramsay: It is also, though, about the sustained infrastructure being there because people’s interest in improving their practice is there if only they will have the practice again next year. Some of the short-term thinking, “Let us do a campaign in this group with this group of providers”, does not necessarily encourage long-term practice. That is why we think the core offer, which is mainly through general practice, is important, rather than just diverting things into other providers, because you then potentially undermine that incentive to deliver a good service yourself.
Baroness Browning: Is that because you see GP practice as the stable plank in the whole thing?
Dr Mary Ramsay: Exactly. That does not mean you do not need supplementary approaches on top of that, but we do not want to undermine that core offer. Then the professionals responsible for that core offer have a responsibility to make sure they provide a good quality service. That will incentivise that.
Q217 Baroness Ritchie of Downpatrick: We have already been talking about UKHSA resources, but how consistently do commissioners and providers use your resources for community engagement and outreach on childhood vaccination? We have taken much evidence over the last 17 or 18 sessions about the drop in childhood vaccinations, maybe a lack of accessibility to those vaccinations, and also the inequities and inequalities in certain population groups and demographics. I have a supplementary as well, but I will first come to you, Julie.
Dr Julie Yates: We monitor the use of our resources, and they are heavily used. The advantages of using those resources are not just that they are consistently developed and the messages are tested so that they are correct and effective, but also a lot of individuals are digitally excluded. In some trusts and areas, for example, that is based on environmental concerns and there is a policy of digital first. While we have seen them move away from our paper resources, we produce both paper and electronic. The paper resources are designed to be environmentally friendly, but also they can stay around and so more than one person can see them. You can leave them on the table in a household. They can be passed around. They can be a conversation starter. They are useful in that way. We do still see them being used particularly to reduce inequity in access to information because not all people have smartphones and can use the HTMLs. They can be a conversation starter between children and their parents and so on. They are still being actively used. We do monitor that usage, as I said.
We also have a publication called Vaccine Update, which provides all the new information and important information for practitioners. That has 77,000 subscribers, and 40,000 people are actively using that at any one time. Those resources are being actively used and those individuals can access them through our “Find Public Health Resources” website as well.
Dr Mary Ramsay: I would like them to be used more. I do hear about them. In fact, when I go into my surgery, the first thing I do is look for the leaflets. I often do not find them, which is annoying. Yes, they are available online as well. Some people want all that information. Some people want shorter information. We need to make sure they are available. Yes, people who know about them do use them.
We go out to conferences and so on, in all the major nursing conferences, and we have a stand to show people there. They are well received. The health professionals like them, as far as we know, apart from maybe in some instances. We are doing our best, but anything that we could do to promote them further is important because we spend a lot of our personal time making sure they are as correct as possible and making sure they are updated. It is a pity if people end up using alternatives because they cannot get a hold of ours.
Baroness Ritchie of Downpatrick: I have a supplementary question. Who, if anyone, is responsible for ensuring commissioners and providers share good practice and learn from effective approaches?
Dr Julie Yates: The responsibility is shared. NHS England has a responsibility for the operational delivery of the programmes. It employs the expert workforce at regional, local level, but is also responsible for commissioning the providers. There is shared responsibility across both of those.
Baroness Ritchie of Downpatrick: How could responsibility and accountability for this be strengthened?
Dr Julie Yates: Strengthening those networks between us at national level and at regional level and then having communities of practice out at local level that are supported by our public health experts can enable effective sharing of good practice, but also of incidents. We want sharing of good practice, but also where things do not work because, otherwise, people reinvent the wheel and they reinvent a wheel that does not work. We are looking for ways that we can share evaluations through a repository such as NHS Futures or our own website. Having those communities of practice or clinical networks is important to share that practice, encouraging people to evaluate and publish what they do as well so that that can be shared. Also, we have a weekly national immunisation network and a national conference that we hold as an example, but we also go out and visit all the regions. Sharing that practice in those arenas is quite important.
Baroness Ritchie of Downpatrick: Mary, do you have anything to add?
Dr Mary Ramsay: With all the churn in the system, it is quite difficult to keep up to date with, literally, contact lists. Free and easy contact information is important as people move around the system so that we can get through to people. As I said, the weekly call we have and the annual conference we have are well attended, but we have noticed a little decline last year, which might be because people are all moving within the system at the moment and they do not know which organisation they will be employed in the future. Someone else mentioned stability being important for helping that network to function properly.
Q218 Baroness Cass: I am not sure if you were in the room when I said that some very senior people in the field—who have been providing a teaching programme for so long that even someone as ancient as me went on it—have written to the ICB querying why it has been stopped. That was a huge worry to me. How consistently are UKHSA minimum standards for vaccination training being met, including the recommendations for staff to be kept abreast of updated programmes? Do you have any sense on that?
Dr Mary Ramsay: Probably this is your baby firstly, is it not?
Dr Julie Yates: It is quite similar to the quality criteria. There is not an assurance process for training, either for individuals being trained or for the assurance and accreditation of training providers at the moment. In England, our immunisation training is, in the main, provided by small independent commercial providers. This is an area of concern and it is a priority for us. We provide the minimum standards and core curriculum, which is what people need to be trained against. That is what you need to be trained and competent against.
We are less assured about how people are being trained. At the moment, we are working together with our colleagues across the system on a framework for action for immunisation training, which looks at the how. That has a number of areas, including understanding what is there now, how that is being delivered and by whom. We are looking at what is needed in terms of training for different groups because we have an expanded workforce and we have different providers now. We also want to ensure that people across the pathway are trained to advocate. Teachers and prison health staff and others may be communicated with about vaccines. We want them to be confident as well to say, “Yes, this is a good thing. This is where you can find out more information.” That piece of work is underway.
Then, once we have that background and we know how people need to be trained, we are looking at cost adoptions for those, and the assurance framework and assurance arrangements should flow from that. For example, if the preferred option after an options appraisal is a centralised training arrangement done nationally for everyone, your assurance framework is quite simple because you have only one provider. If you go for a hybrid where you have all the different providers as we have at the moment, the assurance arrangements are quite complex and potentially quite costly, both for the individual training providers, but also for those who are providing that assurance assessment.
We are working through that at the moment. It would be fair to say that it is inconsistent at the moment. We share your concerns. Some anecdotal evidence shows that because of the changes and the reduction in financial resources, those training providers are starting to say to us that they are not getting the bookings that they had previously, which suggests that people are not going on the training either as frequently as we would require them to be or as often as is needed when new changes or updates are required.
Baroness Cass: I am assuming that it is cheaper to go to private providers than to use senior people and cheaper still to use e-learning resources, but they lose the richness with e-learning resources of being able to ask about difficult questions. If we think about other things like safeguarding, where you have levels one, two and three, there is a difference, and there comes a point where somebody who is needing levels two and three needs face-to-face training with an expert. Is that right?
Dr Julie Yates: That is exactly what we are looking at in that. The second part of this about what different people need. Some people might need motivational interviewing training, for example, because the role that they will have is advocating and having conversations. Somebody who is a specialist at local level, such as our screening and immunisation leads, need highly technical input. We are working on exactly that framework.
We also have a theme in relation to the use of AI, for example, in training and using all of those technologies. It does not necessarily have to be face-to-face, but potentially you can use avatars to do roleplay with people so that they can practice. All those things are being considered and we have a commitment to deliver back on our initial options by September.
Baroness Cass: It is good that you are exploring so widely, but it seems to me that you are doing a lot of the creative work on this but that ultimately the responsibility and accountability will not rest with you. I am not quite clear who is responsible or accountable further along the chain.
Dr Julie Yates: At the moment, it is an employer’s responsibility. It is a requirement within the NHS England service specifications for contracts. We are reviewing at the moment that assurance above that.
Baroness Cass: It is being responsible not just for the delivery but the quality.
Dr Julie Yates: Absolutely. That fits with quality assurance as well.
Baroness Cass: Sorry, Mary, did you want to add anything?
Dr Mary Ramsay: No, I am fine. We have to finish relatively soon. I do not want to hold you up further.
Baroness Cass: Did you want to come in?
Baroness Browning: That was what that last question was what I wanted to find out. Who commissions these things? Yes.
Q219 The Chair: It is all very well having good-quality and relevant training available, but it does not work if people do not undertake it. I noticed that the NICE guidelines say that healthcare staff should undertake training relevant to their role. They do not say “could”, but they do not say “must” either. What is your view about the “must” word? Of course, training costs money. Is enough funding available for everybody who should have training to undertake it? How much is needed if it is currently insufficient?
Dr Julie Yates: Personally, I think part of the difficulty with this is that there are a lot of unknowns. Because the commissioning of the training is by the provider or the employer with an external agency or company, we do not have any involvement in that interaction. That is why we are currently undertaking a piece of work to identify from those providers through our networks who they are employing to do that training, what they are being trained in, and also, where they are willing, how much people are paying for that.
The Chair: Are you trying to identify who is not being trained or are you just talking to the trainers?
Dr Julie Yates: There is no accreditation. A person has to be signed off as competent against the competencies that are in the minimum standards. It is an employer’s responsibility to ensure that their staff are trained and competent to deliver the service, and so the responsibility sits with the employer on that.
NHS England monitors the contracts and so can bring that up in contract reviews, for example, as part of the commissioning of those providers, but there is not an accreditation system for people to feed into to say that they are trained in the way that potentially there is for some screening programmes.
That is quite complex when we have quite a multiplicity of providers now and individuals. Some of them are delivering the whole childhood programme and some are delivering only small parts of it. We are trying to unpick what we need in terms of accreditation of individuals so that we do know that everyone is trained against the standards to the level that is needed but also, where they are commissioning a training provider to provide that training, what is the quality of that training? Is it correct? Is it accurate? Is it up to date? Is it, therefore, providing those individuals with good-quality training that will meet the needs in practice? All of those are pieces of work that we are undertaking at the moment.
The Chair: I am very glad you are because it all sounds a little bit theoretical and a bit tangled. It is easy enough to accredit whether a training course is of high quality. It seems to be more difficult to find out whether everybody who should be having it is having it and is being accredited. Is that right?
Dr Julie Yates: Screening programmes have quite a robust accreditation for each of the training. That is quite complicated and complex. People do not undertake the screening programmes unless they are accredited or have undertaken that training.
The immunisation workforce previously was quite small within the core and now is quite broad. As I said, some people do a little bit of immunisation and for some people it is their main job. That is why we are having to do this piece of work now to ensure that that broader workforce that has been expanded is working to those standards. That expansion of the workforce has happened quite rapidly over the past few years, which is a good thing because it helps with accessibility, but it also poses some challenges in ensuring that they are effectively and appropriately trained and competent.
The Chair: It could get worse if even more people get involved with the vaccination programme. Okay, moving on to Baroness Freeman.
Q220 Baroness Freeman of Steventon: Thank you very much. How much influence does UKHSA have over what data is collected about childhood vaccinations? What has been done to improve access to timely and granular data, and what needs to be done?
Dr Mary Ramsay: The number of outputs and the number of collections we have are expanding. We are collecting it more often and publishing it more often. We have done a lot in that area, largely driven by digital improvements. The improvements in digital flows, particularly now we are getting far more individual data flowing to UKHSA, allows us to drill down quite granularly. The information we had during Covid we are now getting with some other vaccines as well.
We are not yet there with the childhood immunisation as much because most of that is stored locally in general practice or child health systems. We collect data from them, but we get it as aggregate returns, which limits the amount of granularity we can have and the frequency of collection and all those other things.
Baroness Freeman of Steventon: Are you able to influence any of those things?
Dr Mary Ramsay: Yes. We are working closely with the vaccine digital service in NHS England. I am not sure if Caroline Temmink mentioned it, but that has been an area of improvement and revolution. It is going gradually, but we are getting there and they are adding more immunisations to the portfolio.
We must not forget the importance of data quality. That sometimes requires manual involvement. We can control the data we get given and how we publish it, but we do not have that control over how individual GPs are coding it and putting it in the system. We do not have detailed control of that or also how data systems are cleaned, which is key for the denominators. We know that as children move around, someone has to manually take them off sometimes if they have gone abroad. If someone comes in from overseas, you have to manually code what vaccines they had before they came here. We have relatively limited control of data accuracy at an individual level, but we do have a good working relationship with the NHS about getting the data, publishing the data and using the data to look in more detail now, particularly individually with more granularity.
Baroness Freeman of Steventon: I am interested in your mention there of the denominator problem. We have heard of it and we have heard of practices that have done cleaning and that has made quite a dramatic difference to their apparent percentage of vaccination. How big a problem is that? Have you been able to quantify that uncertainty around it?
Dr Mary Ramsay: It is not a new problem. There has been denominator inflation due to what people talk about as ghosts. It is a little bit unfair, but they are people who have moved in and have not been moved out. It is much easier to put someone on a system. It is quite difficult to know they are genuinely not there anymore. That is where the manual checking comes in. If a health visitor visits and discovers a child is not there, they have to take them off the system and those sorts of things. It is quite challenging.
Our denominators are higher than reality, which tends to mean our coverage is lower. We have a good feel for that overall. It is relatively small, but probably in some areas it contributes more. It is a much bigger problem in London. In mobile populations in particular, children under the age of one move in London at phenomenal rates and so keeping up with that denominator is a challenge.
It does not undermine the whole reliability of the data. The data is largely reliable and trends over time are largely reliable. However, you are absolutely right that getting the data right is one way to improve coverage, probably quite quickly, but you have to invest in that long term.
My understanding is that the NHS has launched a big denominator cleaning programme, which will, in theory, remove people from the denominator. Again, it comes back to sustainability. You can do that once, but you have to keep doing it and you have to have systems in place to keep doing it. That is useful not just for immunisation, but for knowing who is on your list and knowing who needs all sorts of other health care interventions. It is important for the health service.
Baroness Freeman of Steventon: Do you know who is responsible for that cleaning in this new scheme?
Dr Mary Ramsay: I do not, but I can find out. I will find out. I will come back to you.
Baroness Freeman of Steventon: Great. Thank you. Julie, did you have anything to add on that?
Dr Julie Yates: No, not on that.
Q221 The Chair: I have heard that it has been suggested that GPs should remove people from their lists if they do not respond for three months rather than six months. Is that particularly dangerous for families that simply do not answer letters and do not have a phone or do not respond? It can be an equity issue.
Dr Mary Ramsay: Yes, I know. As I said, the equity issue works both ways. Having an accurate denominator is important for making sure you are reaching out to the people whom you are responsible for. Any incentive to improve that could potentially have perverse incentives, in particular in some populations. We do not want people taken off lists for no good reason because being on a list is important for their health. Yes, it has to be balanced.
There is a lot of awareness of this issue. We also know that unregistered children are under-vaccinated, but to get them complete, we have to get them on the system because they will not need just one vaccine. They will need multiple vaccines. Getting people registered as well as cleaning people off your lists have to go hand in hand.
The Chair: Indeed. The nominator as well as the denominator needs sorting. Thank you. Baroness Andrews, you are muted at the moment.
Q222 Baroness Andrews: Thank you very much. You probably know that we have asked every set of witnesses we have had what their priority would be for the recommendations. We do not want to make 100 recommendations. We need only three. You can imagine that we have had the same schedule of recommendations to do with leadership, accountability, funding, training, data and so on.
I wanted to ask you for just one top priority that we could recommend the Government to adopt, and to consider the JCVI report, which was presented in 2025 from the UKHSA, which was specific to what you have been talking about today. Briefly, some of the things that it was saying were to stress the consensus of importance around public health systems leadership, improving data recording and flow, which you have just been talking about, regular cleaning, improving access to vaccinations, including concerns for the school-based delivery services, ensuring effective and recall services, tailored approaches to addressing complacency and overconfidence and so on, and another recommendation about training.
I am sorry to rush through those and I know it is pretty invidious to seek just one, but of those in themselves, is there one that you would say, “Just go for that and the rest might follow”, and in relation to the other broader recommendations that people have suggested we also make?
Dr Mary Ramsay: We were hoping that we might be asked for three. The public health system leadership is probably our preferred one because, from that, all the other things can flow. That is our theory. If you have the right people in charge, they can make sure the other things are happening.
Baroness Andrews: The right people in charge at the right level and connected in the right way, though?
Dr Mary Ramsay: With the right competence, background, independence and leverage, I guess.
Baroness Andrews: Yes. Do you want to say anything more about how that might happen, other than what you have told us already? Additional agency or additional connectivity?
Dr Julie Yates: Connectivity is important, but also strengthening the local public health expertise and ensuring that it is maintained through system change because that has moved around the system. As Mary mentioned earlier, it has moved in 2013 from primary care trusts, split into DPH and into Public Health England, moved into NHS England, and is now moving into ICBs or OPICs, the offices for pan-ICBs. There is some uncertainty over capacity, capability and the connectedness of that with us in UKHSA and other system partners. That is a small part of the big transition, but it is so important for immunisation. We cannot stress that enough.
Baroness Andrews: That is a good way of putting it and it confirms a lot of what we have heard. It is about leadership going through the system. Mary, you used the terms “sustainability” and “consistency” throughout the afternoon. It is clear that everyone is looking for, as we heard earlier today, consistency of leadership and programme and provision. I will take that as your top priority. Thank you, Chair.
Q223 The Chair: Thank you very much. How nice it is to end with our witnesses agreeing with each other. As we draw to a close, can I ask you to send us that information from my tricky question from the north-east? I also understand that you intend to send us a package of examples of your materials. They have got stuck in the parliamentary security. Is that right?
Dr Mary Ramsay: It is possible. I saw the dispatch notes, but I did not see the delivery confirmation. We have not had the confirmation.
The Chair: You can confirm they are on their way. Is that right?
Dr Mary Ramsay: Yes. We can resend them. We have a lot of them.
The Chair: We will find those useful. Thank you both very much indeed for the information you have given us this afternoon. It has been an interesting session. With that, I will bring the session to a close.