National Pharmacy Association – Written Evidence (CVX0070)
Authors: Dr Lem Ngongalah, Sygy Collins
What is the evidence on childhood vaccination coverage in England, disparities in coverage, and how coverage and disparities have changed over time
The World Health Organisation (WHO) stated that the UK could no longer be considered ‘measles-free’ due to the declining uptake of the MMR vaccine in 2018. The WHO found that coverage for all 14 childhood vaccines had fallen below 95% rate needed. Please see below for trends in childhood vaccine uptake[1].
NHSE Data Dashboard (2013/4 t0 2023/24) - MMR 1st Dose at 5 Years.
As of 2023-24, 38 of the 149 local authorities selected in NHSE’s dataset met the 95% WHO target[2]. NHS England’s data shows that Cumbria has the highest childhood vaccination coverage (97.2%) and Hackney has the lowest (78.2%)[3]. The Northwest and the Northeast have the highest vaccination rates[4].
London authorities are an outlier compared to the rest of England. Westminster has a vaccination rate of 80.3%. However, vaccination rates decreased by 6.3% over the years prior. Whereas areas with the highest vaccination coverage (Cumbria, East Riding of Yorkshire, and Derbyshire) have seen increases of 0.1 and 0.2, and only a -0.3 decrease, respectively[5].
NHSE Data Dashboard (2013/4 t0 2023/24) – All Vaccines
NHSE’s dashboard shows that, as of 2023-24, all childhood vaccinations have fallen below the WHO’s 95% target. However, 2013-14 figures showed that only the ‘Six in One’ vaccine for diphtheria, tetanus, whooping cough, polio, Hep B, and Haemophilus influenza (DTaP-IPV-Hib at 24 Months) reached the 95% target[6].
The lowest uptake over the ten-year sample is the Four-in-One (diphtheria, tetanus, whooping cough and polio) final five-year booster, with a 88.7% take-up rate in 2013, falling to a 82.7% in 2023/24[7].
Why has childhood vaccination coverage been declining in England, and why are there disparities in coverage? What is the relative importance of different factors (such as access to healthcare and attitudes to vaccination) and how is this changing over time?
The decline in childhood vaccination coverage in England reflects a combination of system-level, access, delivery, and equity factors.
Over the past decade, coverage has steadily fallen across most routine childhood vaccines, driven by weaknesses in how services are organised, delivered and accessed, alongside persistent socioeconomic and regional inequalities.
Key contributors include practical barriers to access, widening deprivation gaps, ethnic and migration-related inequities, and variable confidence and trust in health institutions.
Current evidence shows that practical access barriers, including limited flexibility in appointment times, confusing digital booking systems, last-minute changes and frequent cancellations, are major drivers of both low uptake and delayed childhood vaccination[8]. These challenges are particularly acute for working parents, families with multiple children, and those who rely on public transport or have irregular work patterns, making it difficult to attend appointments during standard clinic hours[9].
Language and communication barriers also limit engagement, as many families lack access to translated information or interpreters and are uncertain about vaccine schedules or reminders.
Patterns of declining uptake are closely linked to deprivation, with more deprived areas and families experiencing greater practical barriers and lower overall engagement with health services. Recent evidence shows that inequalities have widened significantly, as the absolute gap in vaccination uptake between the most and least deprived children increased across all five core childhood vaccines between 2019 and 2023[10].
Children in the most deprived quintile are significantly less likely to be fully vaccinated, compared with those in the least deprived quintile. The growing disparity reflects both reduced access and more overstretched general practices in deprived areas, as well as broader issues of trust, health literacy, and competing socioeconomic pressures. These findings point to deprivation as a structural driver of falling coverage, influencing both opportunity and capacity to engage with vaccination services.
Ethnicity and migration status are both strongly associated with disparities in childhood vaccination coverage in England. Ethnic minority children remain consistently less likely to be fully vaccinated than White British children, although the extent of difference varies between groups[11].
In a large and diverse London population, children from Black Caribbean backgrounds had 70% lower odds of completing their full vaccination schedule compared with White British children, even after adjusting for deprivation and other socioeconomic factors[12]. Similarly, children born outside the UK have substantially lower vaccination uptake - in the same London-based study, non-UK-born children had 90% lower odds of being fully vaccinated than UK-born children. The 2025 National Immunisation Programme Health Equity Audit confirms that ethnic inequalities persist across multiple vaccines and regions, with limited evidence of progress in closing these gaps[13].
As stated above, London consistently records the lowest overall coverage for routine childhood vaccinations and the widest inequalities between communities. This pattern is linked to a combination of factors, including higher population mobility, greater ethnic and linguistic diversity, higher levels of deprivation in many boroughs, and challenges with registering or maintaining accurate vaccination records among more mobile families.
London’s fragmented primary care landscape and heavy service pressures also make it more difficult for families to access convenient appointments, contributing to sustained lower uptake.
Data systems also contribute to declining and unequal coverage. Weaknesses in vaccination records, call-recall systems and data sharing make it harder to identify children who are missing vaccines, especially in areas with high population mobility.
Childhood vaccination coverage data in England relies heavily on Child Health Information Systems, and records become incomplete or inaccurate when families move, change GPs, or receive vaccinations across different services. Poor data quality affects both measured coverage and the ability of local services to follow up under-vaccinated children. Stronger data systems are therefore important for identifying missed children and targeting outreach more effectively[14].
Attitudes, confidence, and trust in vaccination services remain important determinants of uptake and are increasingly shaping disparities over time. While most parents continue to support routine vaccination, some describe appointments as rushed, impersonal, and offering little opportunity to ask questions or seek reassurance. These experiences leave parents feeling dismissed or uncertain, undermining confidence in both the vaccine and the wider service[15]. Families reporting these types of encounters are significantly more likely to delay or miss subsequent doses[16].
Further barriers to uptake include low confidence in vaccines, mistrust of health services, and limited endorsement within communities, particularly among socially disadvantaged and minority groups. These factors often reflect previous negative experiences of care, inconsistent or inaccessible information, and inadequate visibility of trusted local health professionals and community voices[17].
Parents consistently report higher confidence when they can speak directly with familiar healthcare professionals, such as pharmacists, GPs, nurses, or health visitors, while written or online information is often viewed as generic, unclear, or disconnected from their personal circumstances. Addressing these issues requires consistent, empathetic, and culturally competent communication, supported by continuity of care and stronger local relationships, to rebuild trust and sustain vaccine confidence[18].
What would be the best ways to improve childhood vaccination coverage and reduce disparities?
The NPA believes that the government should support and utilise the community pharmacy network to help improve childhood vaccination coverage. Community pharmacy holds a unique position within the health system, as they are already in the heart of neighbourhoods, enjoy a high-level of trust, offer a range of walk-in services, and provide health advice[19].
The UKHSA’s study on the RSV programme in the East of England found that 73% of individuals lived within 5 miles of the pharmacy where they received their vaccine, and almost a third of patients lived within 1 mile of the pharmacy where they received their vaccine[20].
Community pharmacies have already successfully offered expanded NHS services through the Covid and Flu vaccination services and the Pharmacy First Programme. Further groundwork for an expanded childhood vaccination service commissioned through the government has been laid out in the launch of this year’s Seasonal Vaccination Service for Covid and Flu. The new advanced service will allow pharmacies to offer both vaccinations, which replaced the previous separate commissioning model. This enhanced commissioned service demonstrates that community pharmacies can offer children multiple vaccinations through any commissioned programme.
Recommendation One: The NPA believed that a national framework, allowing for local commissioning and mirroring the above advanced service, would enable Integrated Care Boards to roll out a similar service in areas with low uptake, such as the London Boroughs of Westminster and Hackney.
It is important to distinguish between vaccine coverage (the availability and accessibility of vaccination services) and vaccine uptake (whether families choose to vaccinate their children).Vaccine hesitancy among certain demographics remains a barrier to uptake. NHSE found that vaccine hesitancy is highest among black people, followed by Bangladeshi and Pakistani people[21]. NHSE notes that national communications campaigns have not laid the groundwork for tackling hesitancy among these BAME populations, with the NHS noting that the spread of misinformation (Social media, blogs, online anti-vaxxer groups) has ‘dramatically outpaced efforts at rebuttal’[22]. The anti-measles and mumps vaccination movement is believed to have caused a sharp increase in cases of the diseases in England in 2019[23].
Recommendation Two: The NPA would call on the government to work across departments to roll out a targeted health information campaign aimed at vaccine-hesitant communities to highlight the benefits of vaccines, dispel social media misinformation, and signpost families to community pharmacies for vaccines as pharmacists can vaccinate ‘then and there’ on
premises. Any targeted campaign should focus on underserved communities or those who may face language barriers. The government should consider co-production with pharmacists
located in diverse areas to ensure any awareness campaign reflects local demographics.
What are the strengths and weaknesses of the evidence base on childhood vaccination coverage; the drivers of the decline in coverage; and how to improve coverage and reduce disparities?
Please see our above recommendations: Commissioned childhood vaccine programme in ICBs with low uptake and the national awareness campaign.
However, to underpin coverage to allow uptake, we believe that the community pharmacy sector must be kept financially afloat. The sector is currently facing immense financial pressures and the NPA is mindful that Community Pharmacy England and the Department of Health and Social Care are currently in the negotiation period for the next funding package to underpin the next Community Pharmacy Contractual Framework (CPCF).
Community pharmacies are going out of business due to chronic underfunding with a decade of real-terms funding cuts whilst delivering considerably more activity both in terms of prescription items and clinical services like Pharmacy First, contraception and BP checks[24].
During this time they have absorbed increases in business rates, rises in the National Minimum Wage and National Insurance Tax, volatility in medicine prices, and inflation. (Annual shop price inflation rose to 1.4% in September from 0.9% in August[25]). They also stepped up for the nation during the COVID-19 vaccination programme.
1,200 pharmacies have already closed. The 4% funding uplift in 24/25 and a 14% uplift in 25/26 has not fully addressed the impact of a real-term cut of at least 40% since 2015. More pharmacies are closing their doors. NPA found that a significant proportion of pharmacies could close this year without further support.
Who is responsible and accountable for reversing the decline in childhood vaccination coverage and reducing disparities at national, regional, and local level in England?
The Department of Health and Social Care and the UK Health Security Authority would commission coverage, underpinned by Treasury funding and delivered by local NHSE ICB networks.
How clear are lines of responsibility and accountability?
The 2023 NHS Vaccination Strategy[26],aims to make vaccinations easier to access, locally led and of ‘high quality, convenient to access and tailored to the needs of local people’ aligning with the government’s ambitions in the 10 Year Health Plan to shift healthcare into the community.
The Vaccination Strategy sits across arms-length bodies like NHSE and the UK Health Security Authority, as well as the Department for Health and Social Care. The strategy consists of the following themes:
1) Simple, convenient and efficient front door to service;
2) Target underserved populations through data-driven, focused outreach;
3) The need for integrated, multidisciplinary teams;
4) Strong system leadership;
5) A new commissioning and financial framework;
6) An integrated, flexible vaccine workforce;
7) Timely and accurate data;
8) Efficient and responsive vaccine supply;
9) Outbreak response capability.
Has the Government identified the right priorities for reversing the decline in childhood vaccination coverage and reducing disparities (including in the 2023 NHS vaccination strategy and the NHS 10-Year Plan)? If not, what should the Government prioritise instead?
The above vaccination strategy aims to increase coverage and uptake nationwide and has enabled the current rollout of the flu and Covid vaccination programmes, including flu vaccines for 2-3 year olds. To date, community pharmacy has administered over 46,000 childhood flu vaccinations to children, which is a promising start[27].
The Record of Vaccination service has included community pharmacies in vaccination pathways. However, the National Booking System for vaccines does not currently integrate with community pharmacies’ internal booking system for vaccines.
Recommendation Three: As part of the shift from analogue to digital, the NPA calls for the National Booking System to be able to integrate with Community Pharmacies’ internal vaccine booking system to break down internal digital barriers.
How effectively has the Government been delivering the commitments in the 2023 NHS vaccination strategy? Why has delivery been effective or ineffective?
At time of writing, the influenza vaccine programme for 2-3 years has not been confirmed yet for the coming winter, running the risk of making it difficult for community pharmacists to plan ahead of flu season.
How accessible are childhood vaccination services, both for the general population and for people in under-vaccinated groups? What are the main barriers to making childhood vaccination services more accessible for all, and how could those barriers be overcome?
The 2-3 year old flu service has not been commissioned nationally, with adoption in only three places; we would like to see this rolled out more widely. As per our above recommendation, to address vaccine hesitancy in rollout areas, we would call for an awareness campaign to complement the rollout.
How effectively and equitably are childhood vaccination services funded? How could funding arrangements be made more effective and equitable?
The NPA calls for a nation-wide vaccine service commissioned through the Community Pharmacy Contractual Framework (underpinned by DHSC and Treasury funding to our sector).
What can the UK Government learn about improving childhood vaccination coverage in England from Scotland, Wales, Northern Ireland, and/or other comparable countries?
The International Pharmaceutical Federation (FIP) found that pharmacy-based vaccine pilots in France, Ireland, Belgium, Estonia and Poland have shown high patient satisfaction with pharmacist-administered vaccines, with patients emphasising convenience and professionalism[28]. Furthermore, surveys in Canada and Germany highlight strong patient satisfaction and willingness to use pharmacy-based vaccination services[29].
The Canadian pharmacy model allows for community pharmacies to administer childhood vaccinations in most provinces[30]. Studies have found that Canadian pharmacists are willing to adopt a proactive vaccinator role, which includes routinely engaging patients in health discussions about their vaccine status, eligibility, and administering vaccines over the lifespan[31].