The Health Secretary Sajid Javid announced in the House of Commons today that frontline NHS staff in England will have to be fully vaccinated against COVID-19 by April 2022.
Dr Peter English, Retired Consultant in Communicable Disease Control, Former Editor of Vaccines in Practice, Immediate past Chair of the BMA Public Health Medicine Committee, said:
“This statement had been widely trailed.
“I am clear that all NHS staff should be fully vaccinated (apart from the vanishingly small number who have a genuine medical contraindication – and perhaps such individuals should be redeployed to lower-risk roles).
“I have outlined previously the arguments for this, both legal and moral.
“Professionals already have a duty to be vaccinated, as I explained recently.1 Health and safety, and public liability legislation already create a duty on NHS Trusts to ensure that their staff, patients, and visitors are safe.
“I would rather not see staff working in the NHS who choose not to get vaccinated, as this puts not only them, but also puts their co-workers and patients, at avoidable risk.
“I went into more detail on the principles behind this a few years ago.2
“Before legislating, I would hope we had already done all we can to win over the small minority of as-yet-unvaccinated staff. Have we addressed their concerns? Are we making the vaccinations as accessible as they need to be? Would small incentives in cash or in kind help? If incentives would help, but they are not currently permitted, or have e.g. tax implications that nullify them, have we addressed that?
“I have three reservations about changing the law in this way.
“My first reservation is practical: making vaccination compulsory may stimulate a backlash against vaccination that could have the opposite effect to that intended; that more people will refuse to be vaccinated (or try persuade others not to be) than would otherwise have been the case.
“The second is the timing. Winter is starting now. We can expect to see more cases of influenza, Covid-19, and other seasonal infections; and hospital bed-occupancy rates are already very high. We need staff to be protected, and to reduce their chances of spreading the infection, right now. Does it make sense to give them space to leave it until April, when winter will have passed?
“The third relates to staff recruitment and retention. Concerns have been expressed that staff may, possibly, choose to leave to avoid having to be vaccinated (or be sacked if they refuse).
“A decade or more of austerity and real-terms pay cuts has left the NHS desperately stretched. We cannot afford staff leaving if we can avoid it.
“On the other hand, in, for example, New York, firefighters and police officers were obliged to be vaccinated and there were warnings of a mass exodus: in reality only a handful left. Other countries who have implemented mandatory vaccination of healthcare workers have not, as far as I am aware, seen major staff losses, and I would hope that would also apply in the NHS.
“It is also possible that the mandate might help with recruitment and retention. The vast majority of NHS staff have already been vaccinated; and knowing that your co-worker is not going to infect you or your patients – and that there will not be antagonism between staff who choose not to get vaccinated and the vast majority – might help with recruitment and retention. It is very hard to predict what the effect of this legislation on staff recruitment and retention will actually be.”
Dr Ben Kasstan, a medical anthropologist at the University of Bristol, said:
“After much speculation, the Health Secretary has announced that NHS frontline staff will need to be fully vaccinated by 1 April 2022. The vast majority of NHS healthcare workers have already been vaccinated against COVID-19, and hopefully this policy will prompt remaining frontline staff to protect themselves and the patients they care for. The Health Secretary has said exemptions on medical grounds will be made available to frontline staff, but we still need more transparency and consistency on the penalties for frontline staff refusing vaccination in April 2022.”
Comments sent out on Tuesday morning in response to BBC News report suggesting COVID-19 vaccination will become mandatory for frontline NHS staff in England, before it was confirmed by Sajid Javid this the Commons this afternoon:
Dr Simon Williams, Senior Lecturer in People and Organisation, Swansea University, said:
What do we know about uptake of vaccines when they become mandated among health care workers?
“In France1, only a very small proportion (0.1%) of healthcare staff who refused to be vaccinated have left their jobs.
“Research including our own highlights that vaccine hesitancy actually occurs on a spectrum. Not all those who have not yet been vaccinated are opposed to getting a vaccine, and relatively few are actually actively anti-vax. Most are simply undecided or feel like don’t have enough information., or perhaps feel like they are not in a hurry to get vaccinated. And so vaccine mandates are unlikely to persuade those who are anti-vax or opposed to vaccines to get vaccinated – for them, mandates may have the opposite effect, and encourage them to double-down in their opposition to vaccines. But for those who have been putting the decision off – we refer in our research2 to vaccine delay as a specific type of hesitancy – many feel like they will get vaccinated when they need to – and these type of mandates will speed up the decision
What are the benefits and risks?
“One recent review3 found that there were both benefits and risks to vaccine mandates. One risk is that possibly staff could be deterred from staying in, or entering, health care work – in a sector that is already overstretched and overburdened. A recent review by Professor John Drury and colleagues found that “where vaccination is seen as compulsory this could lead to unwillingness to accept a subsequent vaccination”. And so people might choose to leave the workforce rather than be forced into vaccination.
“However, although it has been a very divisive issue in the UK, most opinion polls4 suggest that a majority support the introduction of vaccine mandates or ‘passports’ n healthcare settings. Also, to put it in context, a number of countries are implementing far more substantial vaccine requirements – for example the US and Canada that
“Also, in France, the concern that staff will leave the sector has not been warranted – with only a very small proportion (0.1%) of healthcare staff who refused to be vaccinated have left their jobs.
“Thinking about this in terms of balancing risks and benefits is helpful. I think it is important to acknowledge people’s concerns that vaccine mandates are a new challenge to, or even imposition on individual rights – denying people’s concerns is unhelpful. But we can also argue that there are benefits, and from a public health perspective, the benefits can outweigh the risks. Certainly from the perspective of those who are admitted to hospital and that might be treated by someone who is at higher risk of unwittingly carrying or transmitting the virus by virtue of the fact they haven’t been vaccinated, the benefits of staff being guaranteed to have been vaccinated is very beneficial and reassuring.
“Some have argued5 that there is on face value a case for mandatory vaccination on the ‘do no harm’ principle that all medical practitioners abide by.
“Although a mandate might lead to some healthcare workers leaving the profession, being at higher risk of becoming ill from covid or passing it on can also be disruptive.
Do we know the reasons why NHS staff may not be taking up the vaccine? Will a mandate help with those issues or are additional interventions needed?
“The reasons why a proportion – and it is worth emphasising a very small proportion – of NHS staff are not taking up the vaccine are the same reasons as those in the wider population who are not taking it up. Lots of research on this, including our own studies, has found that some of the main barriers to vaccine uptake include concerns over possible-side effects, a lack of trust in government and authorities, a stated preference for ‘natural immunity’ (that is getting antibodies by catching the virus), and conspiracy theories and misinformation. And so even though overall uptake is high in the adult population – more can be done to increase it further, so that it reaches levels seen elsewhere like in Portugal. Vaccine mandates in very select settings – like healthcare settings – are one way. I would be concerned to see mandates rolled out more widely beyond healthcare for job purposes.
“I don’t think we will see this in the UK. But there are also other ways to increase uptake. For example, we can’t rapidly rebuild trust in the UK government – we are beyond that – but we need to really emphasise the independence of the vaccines from politics – those who see vaccines as being associated with science and healthcare rather than politics are more supportive of their need. Some have raised concerns6 that vaccine mandates can further harm trust in, and between, authorities and the public.
“Also, we still have a long way to go on misinformation, and even amongst those with scientific training and education, misinformation is still influencing a small number to not get, or to at least hesitate about getting, a vaccine.”
Prof Dominic Wilkinson, Professor of Medical Ethics, and Member of UKRI Pandemic Ethics Accelerator, University of Oxford, said:
“There are two key questions that need to be considered if we are trying to work out whether a vaccine mandate is ethical. First, is it proportionate to the harm we are trying to avoid, and second, is it necessary?
“It is proportionate to require care home and NHS workers to have the vaccine – after all, these vaccines are extremely effective and may help prevent workers from passing on the virus to some of those in our community who are most vulnerable and at highest risk from COVID.
But is it necessary?
“The government policy on vaccination for care home staff (and potentially the policy for health care workers, unless it changes) is overly simplistic in focusing only on vaccination, when what matters most ethically is the risk of passing on the virus.
“Many healthcare workers and care home staff will have contracted the disease during the pandemic.
“And there is also now evidence to suggest that natural immunity confers comparable protection to vaccine-induced immunity (at least in the short term).
“Based on what is now known, individuals with sufficient proof of natural immunity should be granted a medical exemption to the vaccine mandate being placed on care home workers and NHS staff. This would be a simple ethical policy adjustment. It would prevent the loss of valuable workers who do not pose an increased risk of transmitting coronavirus to vulnerable residents and patients.”
Prof Robert Dingwall, Professor of Sociology, Nottingham Trent University, said:
“Mandating vaccinations is a superficially attractive but simplistic response to a complex problem. Our colleagues in behavioural science have already expressed concern about the psychological impact. As a sociologist, I am looking more to the organizational impact. In an organization as large and complex as the NHS, who actually counts as frontline staff? This is very different from mandating hepatitis B vaccines for narrowly-defined groups engaged in specific tasks. With such a broad mandate, there is considerable potential for varied interpretation between NHS sites, introducing inequities and concerns about fairness and avoidable grievances. The mandate is also likely to bear more heavily on certain minority groups, compounding the history of insensitive handling of diversity issues within some parts of the NHS. If the result is that the NHS loses a significant number of staff, this will simply compound the shortages that are already stressing the organization. These staff may not be lost randomly, with serious consequences for those hospitals that depend heavily on workers from groups that the vaccination programme has not successfully reached. This is likely to throw further burdens on colleagues who are already over-stretched and whose morale may be further undermined by seeing valued friends and collaborators leave because of management actions that may seem arbitrary and over-reaching.
“It is also far from clear what problem is being solved, beyond symbolising that ministers are doing something. Studies have shown that while vaccination reduces transmission risk a bit, it does not fully prevent the transmission of infection in either direction. Health workers are still likely to become infected by patients and vice versa, although they will be less likely to develop serious infections or die. Similarly, patients will be protected, or not, by their own choices about vaccination. If other infection control measures are in place, will vaccination necessarily add very much?
“The delay is welcome in providing time for NHS management to engage with reluctant staff members. This is an area where sensitivity, a sympathetic ear for concerns and a commitment to persuade rather than sanction are desirable. Unfortunately, NHS management cannot always be relied upon to deliver this, not least because they are subject to many of the same stresses and workload pressures as the frontline professionals. This should be an opportunity for teams within the NHS to move forward together. I would be delighted but surprised to see that happen.”
Prof Jonathan Ives, Professor of Empirical Bioethics at the University of Bristol, said:
“There is a very strong argument for people working in patient facing clinical roles to be vaccinated, because unvaccinated clinical staff run a much higher risk of putting patients’ health at risk by passing on the virus. Unvaccinated persons also put themselves at higher risk of catching the virus, and needing time off work themselves, which will lead to staff shortages at a critical time when all hands are needed. If either of those harms can be easily avoided it seems obvious that we should do so, and getting vaccinated is an easy and effective means of doing this. It will protect individual patients, protect public health, and protect the NHS.
“It is also important to note occupational health clearance is already needed to work in clinical areas, and this requires a number of vaccinations – which people have to either accept or they do not work. The addition of one more vaccination to this list does not seem immediately problematic. (Although, having to agree to something upfront is different to having to agree to it after the fact.)
“However, the difficulty with this is that – rightly or wrongly – some people are very sceptical about the Covid-19 vaccine, and some are genuinely afraid of it. They fear it was developed too rapidly, and they do not trust the research that says it is safe and effective. I believe they are wrong to think this, but that is immaterial. It is true people will still have a choice whether or not accept the vaccine, but forcing people to choose between losing their job or putting something they, rightly or wrongly, fear into their bodies is a highly coercive measure that will have harmful consequences and will erode trust and goodwill. It could certainly lead to people leaving their clinical jobs, which will have a negative impact on the NHS.
“If we are serious about respecting people’s autonomy – their right to choose for themselves – it is always better to adopt the least restrictive or coercive measure possible. So we really need to be confident all other options have been considered before we adopt a policy of compulsory vaccination.
“This is a genuine moral dilemma – in which we cannot do right without also doing wrong. I believe vaccination is a good thing, and the more clinical staff who are vaccinated the better the NHS will be able to cope with the coming winter. I suspect mandating the vaccine will probably, overall, increase vaccine uptake amongst clinical staff, and will help the NHS cope with massive demands on it, which will benefit us all. But this will come at a cost, and we cannot ignore the fact this kind of decision – even though it may be the right one overall – will also lead to people being both harmed and wronged.
“If vaccines are mandated, it is absolutely essential a conversation continues between the NHS and their vaccine hesitant staff. Reason and persuasion are still the best way to go about increasing vaccine uptake, and making it compulsory must always be a last resort.”
Danielle Hamm, Director of the Nuffield Council on Bioethics, said:
“Delaying making COVID-19 vaccination a condition of deployment for all healthcare workers until the spring is to be welcomed. It is important that the Government doesn’t rush into this as the policy could have serious implications for staffing, and health care workers are already in short supply as we head into winter.
“We urge the Government to now spend time exploring more thoroughly the reasons why some are not taking up the offer of a vaccine, and give full consideration to other incentives and interventions that may be more effective without risking serious consequences for staffing and care of patients.”
Dr Ben Kasstan, Medical anthropologist at the University of Bristol, said:
“While we are still waiting for directives from the Health Secretary on requiring COVID-19 vaccination among NHS staff, this step should not be seen as significant or controversial but rather in line with public health policies on vaccination that have been implemented in France and the USA. We have to remember hundreds of NHS workers died during the first year of the COVID-19 pandemic, and COVID-19 vaccines are important to protect healthcare workers and the patients they come into contact with. The requirement for healthcare workers to be vaccinated against infectious diseases is not new. NHS Trusts in England make very clear that staff who have direct care responsibilities and contact with bodily fluids must be vaccinated against hepatitis B and not following this policy can jeapordise employment. The Health Secretary should put an end to speculation by outlining clearly which healthcare workers will require vaccination, by what date, and what exemptions (e.g. medical only) will be made explicit. If the requirement will not come into force until April 2022, as speculated, then there is plenty of time for professional bodies (British Medical Association and Royal College of Nursing and employers (NHS Trusts) to understand what concerns, if any, healthcare workers have and how to address any issues in confidence, convenience or complacency. It is important to ensure continuity in care and not risk disruptions to urgent or non-urgent procedures, so it would not be in anybody’s interests to suspend healthcare workers who refuse to be vaccinated – as occurred in France. It is likely most healthcare workers who have not yet been vaccinated against COVID-19 will comply with the policy, if implemented. There does need to be transparent consultation on what penalties would be proportionate for healthcare professionals who refuse COVID-19 vaccination despite current evidence.”
Prof Helen Bedford, Professor of Children’s Health, UCL Great Ormond Street Institute of Child Health, said:
“When there is concern about less than optimal vaccine uptake rates, making vaccination mandatory can seem the obvious solution but it can backfire. It may make people who are just unsure about vaccination more resistant. The reasons that health care staff may not be taking up the vaccine are similar to those in the general population with concerns about safety or necessity of vaccination always top of the list. However, access to vaccination or difficulties booking an appointment may also be a barrier for some people. There is plenty of evidence showing that it is preferable to provide opportunities to discuss vaccine concerns openly and non-judgmentally with people who have doubts and to ensure there are adequate opportunities to access vaccination. These initiatives have already been found to be effective in UK hospital settings. Mandation should be the last resort when these other measures have not been successful.”
All our previous output on this subject can be seen at this weblink:
Prof Robert Dingwall: “Paid consultant to AstraZeneca on general issues around vaccine hesitancy.”
Prof Helen Bedford: “Member of NICE committee developing guidance on vaccine uptake in the general population.”
None others received.