Oral evidence: Vaccinations, HC 1695

Oral evidence, 11 February 2026.

Witnesses

Dr Ben Kasstan-Dabush, Dr Amit Aggarwal, Greg Fell and Fin McCaul.

Chair

Welcome to this one-off session of the Health and Social Care Committee on vaccinations. There will be two esteemed panels today. Let us begin by introducing our first panel of witnesses.

Fin McCaul

I am a community pharmacist from north Manchester, here representing Community Pharmacy England. I am a practising pharmacist on a daily basis.

Greg Fell

I am president of the UK Association of Directors of Public Health, and I am the DPH in Sheffield.

Dr Kasstan-Dabush

I am assistant professor of global health and development at the London School of Hygiene and Tropical Medicine, and lecturer on global health policy at the University of Edinburgh.

Dr Aggarwal

I am executive director for medical affairs and strategic partnerships at the Association of the British Pharmaceutical Industry.

Chair

Thank you all for coming. We host this session in the context of concerning declines in vaccination rates over the last few years. This country lost its measles-free status just last month, so we felt that a one-off session to look at this was timely, especially with the rise in winter flu, RSV and covid cases that we are also seeing in our A&Es. We recently did a report called “The First 1000 Days”, which branded the UK strategy a failure and asked the Government to develop a new plan with a specific focus on improving vaccination uptake in early years settings. I wondered how much you agreed with that statement.

Dr Aggarwal

I note the “First 1000 Days” report, and it is good to be back in front of the Committee. We believe that the vaccination strategy is the right approach. Bearing in mind that the decline in vaccination coverage has been a long event happening over the last 10 or more years, that roughly 12-year decline in vaccination coverage is not going to be reversed overnight, particularly at a time when NHS primary care is under significant pressure. Families face cost of living issues that create barriers to access in terms of parents taking time off work, and vaccine misinformation and disinformation continue to be a problem and, in some instances, continue to grow. But there are early green shoots: flu vaccination rates have increased this year, and there has been a recovery in the maternal whooping cough vaccination coverage as well. It is true to say that no programme is currently reaching the WHO 95% threshold, but there are some green shoots of recovery. In terms of the implementation of the strategy itself, there are some noteworthy achievements: improvements to operational data and data flows to support delivery of the school-age vaccinations; changes to workforce regulations have been consulted upon and laid in Parliament to build on some of the covid workforce innovation that took place; and there has been a really important expansion of vaccination through community pharmacy and outreach services, as well as sharing best practices. So the strategy is the right one, but it will take time to implement.

Dr Kasstan-Dabush

Just to echo a lot of those comments, I did not agree with the recommendation to scrap it—we need to recognise that. It has been tasked with an enormous challenge to undo the damage caused by austerity-era policies, which affected both the immunisation system and the way that families engage with that system, so there is a lot of recovery that needs to take place. As we have just heard, there is evidence of progress, but the ability to advance the immunisation strategy really depends on how we reconcile it with the policy changes that are taking place. For example, a commitment to the Best Start family hubs in every local authority and scrapping the really cruel two-child welfare benefit cap. So there are opportunities on the horizon with which we can really have some alignment. There are tremendous challenges, of course, as you know. Do you want me to stop?

Chair

We are going to cover a lot of this issue. You do not agree with that, and you have explained why. Greg?

Greg Fell

I have four quick thoughts. The strategy is basically a good one. It is not an enormous tome, and there is something to do with the detail and local implementation. Access and ease are by far the most important things. We need to look at the basic building blocks and doing dull stuff well consistently over decades. I cannot get away from the fact that there is immense pressure in some aspects of the basic delivery system, particularly the primary care aspects of both the flu and seasonal vaccinations, but also childhood vaccinations. They are the backbone of this, and primary care is under immense pressure. Misinformation and disinformation are definitely a thing, and there is something to do about looking at the basic systemic drivers of that—it is largely trust in institutions—but in my view access is way more important than misinformation.

Fin McCaul

Greg has stolen my thunder.

Chair

I was going to say that this is your bag.

Fin McCaul

But in turn, the strategy is the right strategy, we just need to tweak and develop it and move it forward. Community pharmacy has shown how it can help with a lot of the challenges within the programme and deliver this in a more constructive manner.

Chair

What I am hearing is that we have perhaps jumped the gun in calling it a failure, as there have been some green shoots, but it is not a success either. On what timeline do you think this Committee should come back and finally judge whether it has been a success or not? One year? Three years? Five years? Just give me one number, and I will give you that a year’s tolerance is built into it.

Dr Aggarwal

One important milestone is the delegation of responsibilities to ICBs.

Chair

Just give me a number.

Dr Aggarwal

Two years.

Dr Kasstan-Dabush

Two to three years, with an evaluation in between.

Greg Fell

Ditto.

Fin McCaul

Two to three years.

Chair

Lovely. That is within this Parliament, and it is therefore within our gift, so thank you—it is much appreciated. One of the big changes that is going to be happening within that timeframe is, of course, that ICBs are meant to be the strategic commissioners, or they will move to it once the legislation is brought to and passed by the House. That has been delayed, perhaps understandably, given all the turmoil in ICBs. I just have a quick question. The reason I am hurrying you—and I will hurry you continually for answers—is that there are four of you on the panel with a lot of knowledge, so if someone repeats, just move on. It is all taken as read; unless you disagree, in which case actively disagree. Do you think that the move to ICBs becoming the main commissioner of this is the right move? Also, do you see the delay as basically an admission that they are not ready for this? If you add in the 50% cuts and the turmoil, with people worried about their jobs, they do not know exactly what this is going to look like. April ’27 feels a long way away, but in the context of vaccines, it is not. How do you think this is going to go, and how does that affect the timeline that you gave me?

Greg Fell

Unclear, is my honest answer. It will be for the OPICs—the offices of pan-ICB commissioning—to lead on this, as they will be the vaccination experts. They will be hosted in one ICB on behalf of a broader region, and they will provide the leadership and the technical ability. Some of the business end of delivery and the co-ordination within their strategic commissioning role will need to be done by the ICB. There is a moot point on whether co-ordination of the delivery system is strategic commissioning. Someone, somewhere will have to co-ordinate the delivery system, and the views on whether that counts as strategic commissioning will vary up and down the country. The 50% headcount will undoubtedly have an impact on this—the obvious day-to-day impact of the 50%—but there will be fewer people to do the same broad level of stuff, and the delivery of vaccination is one tiny part of what ICBs will need to do. So in all of that uncertainty, the impact that the transfer of responsibility from NHSE to ICBs—OPICs—will have in reality is unclear.

Chair

Would you accept it is a risk?

Greg Fell

Yes, undoubtedly. Let me be clear, there are many skilled people who are trying hard to mitigate that risk and do the right thing, but it is a structural risk.

Chair

How would you suggest to Government that they mitigate the risk? To delay further until we know what we are dealing with, for example. What do you think ought to happen?

Greg Fell

I am not sure that further delay would help because it provides more time to delay. I would be trying to specify and be really clear what exactly the expectations are on ICBs with respect not to the delivery but the co-ordination of the delivery system: spotting problems when they arrive and actively solving them, and who has what responsibilities in that context. I would be trying to specify that as much as possible, rather than getting into a very detailed, “On Thursday, X ICB will do Y.” But the specification of who has what accountability is well overdue.

Dr Kasstan-Dabush

It is a huge concern to place more responsibilities on ICBs for vaccination while expecting them to cut to such an extent. My particular concern in this space is what this means for equity and the roles and delivery strategies that really underpin outreach methods. We know that they are more expensive, and hence could possibly be vulnerable to these changes. We really need to understand the impact assessments on what has been done to mitigate the risk at regional level of further undermining vaccine coverage recovery.

Chair

Who will have done those impact assessments?

Dr Kasstan-Dabush

I would hope it is at ICB level.

Dr Aggarwal

Undoubtedly delays are never desirable, but at the same time, given the recognition that ICBs were not ready, delaying until April ’27 is the right thing to have done. That transition will clearly need really careful monitoring and very clear guard rails and expectations around coverage levels, for obvious reasons. For our part, we have partnered with the NHS Confederation, recognising the fact that there is a big uplift to do in terms of ICB readiness for this. We have actually produced some resources with the NHS Confederation, which is a resource hub that has case studies and advice on how to manage that transition, but undoubtedly it presents a risk. In terms of that readiness, between now and April ’27 an ongoing process of monitoring and determining the readiness is really essential, rather than that being absolutely set in stone.

Chair

Are you saying that there could be some ICBs that are ready and some that are not, and that we need to take this case by case?

Dr Aggarwal

Yes.

Chair

Understood.

Fin McCaul

We think there are a lot of risks associated with it, and that by going down to that level, there is a lot of duplication. So what we can do at a national level and what we can do at a local level has to be clearer. We have had an incident in—

Chair

Can you give me some examples of something that you think is best done nationally, and something else that is best done locally?

Fin McCaul

Signing off protocols at a national level for the use of PGDs or for local vaccinations. We had some hiccups in Manchester this year due to the lack of ability to do it because of the local structures—that is one example. We also have supply, which could be issued at a national level through pharma, and it is really experienced in doing that, rather than trying to duplicate systems at a local level. Expanding the ability to have mop-up clinics and the role that community pharmacy could play in it. If we look at childhood vaccinations over the winter, we were able to do two to three-year-olds, but there was a problem with schoolchildren as we had not been given the powers or the permissions. Again, if that had been signed off nationally rather than trying to do it 150 times locally, it would have been so much easier.

Danny Beales

I am going to be talking to you about vaccine hesitancy and misinformation, and some panellists have touched slightly on this topic already. Studies identified by Ofcom in 2025 found that a notable minority of the public believe covid-19 vaccine conspiracy theories, and that there is a link between these beliefs and vaccine hesitancy, but there is mixed evidence. What is your view about the role that vaccine hesitancy and misinformation have in the lower rates of vaccination coverage that we are seeing?

Greg Fell

Vaccine hesitancy and misinformation is definitely a thing. In my view, it is nowhere near as important as improving access, by some considerable margin. The autism myth is alive and well, coming from family hubs and places, and the belief that the covid vaccine causes cancer is alive and well, coming from some prominent mis- and disinformation “experts” with very big social media coverage, though that one has been debunked comprehensively on a number of occasions. These stories are alive and well, and I hear them a lot. Bluntly, in my view, they are nowhere near as important as a push on access and availability.

Danny Beales

Do you have to do one or the other, or can you do both?

Greg Fell

You need to do both, but I would pay much more attention to access and availability.

Danny Beales

You have already said that the strategy is right, that misinformation is not the major factor and that it is about access. Do you have evidence that access to the health service has decreased? Viewing it from my perspective of what we can see, there are a number of initiatives to widen access points. The proposition I put to you is that the number of access points is probably more than it has ever been and the number of vaccines is more than it has ever been, so is it true that it is just about increasing accessibility? There seem to be more places to get vaccines than ever, but there are also lower take-up rates, so how is it correlated to access?

Greg Fell

Two thoughts: there are more places and there is more access, but there is probably less co-ordination and more confusion because there are more access points and entry points into the system. There are not the stitchers-together to do some of that stuff, so that creates some confusion because of the basic pressure in the delivery system. If I miss the letter that is in the school bag or the 1,000 texts I get from school every day, I may not take my kids to be vaccinated. That is an access issue rather than a misinformation issue. People get missed in the mess, and we do not have the fail-safes to get people back. Lastly, on mis- and disinformation, I am not saying it is not a thing—it definitely is a thing. If I had to do things in that space, I would come back to basic trust in institutions and healthcare professionals. Trust is at the very base of the systemic drivers. Very specifically, if folk have questions at an individual level—people have legitimate, specific questions about vaccinations and many other healthcare interventions—I always tell them to go to speak to GPs or health visitors, because that is what they do and they are really good at it. They are broadly still trusted.

Danny Beales

If you believe a conspiracy theory or misinformation, are you likely to go out and seek a GP?

Greg Fell

Maybe not, but sadly I cannot change what people believe. That is easier said than done.

Danny Beales

Is that not the proposition? Should the NHS and the Government be actively trying to promote factual information around vaccinations?

Greg Fell

Yes, and that being vaccinated is the norm. Most eligible people are vaccinated, and that is certainly the case with regard to MMR, now MMRV. We can do better on coverage, there is no doubt about that, but the norm is that most people choose to be vaccinated. Promoting calm, evidence-based advice—which UKHSA does an amazing job on—is translated by healthcare professionals day in, day out. Just consistently doing that stuff well is part of this. If we are getting into mis- and disinformation, and we should, we should do so very strategically and get into the structural drivers of mis- and disinformation, as opposed to continually firefighting and debunking because that is really hard to do.

Danny Beales

Do you want to elaborate on how you tackle the structural drivers of misinformation? What would that look like?

Greg Fell

Trust in systems, addressing weaponised amplification via algorithms on social media, and making sure the message deliverers have the right information and feel skilled and confident when they get questions from parents, patients and citizens—I can only speak with alacrity at local level—but those are some of the spaces. Various people have written very eloquently about mis- and disinformation—

Danny Beales

Does anyone else have any thoughts about how systems, locally or nationally, could be supported to tackle misinformation, or to improve vaccine confidence?

Dr Kasstan-Dabush

My big hope is that, with the return to the Best Start family hubs, we can once again offer vaccinations as part of a broader commitment to a family’s health and wellbeing. That is recreating these really crucial touchpoints just to talk about vaccination, hear from a health visitor and address concerns and questions. It is really rebuilding the touchpoints to engage in these conversations. Having worked for many years in under-vaccinated communities, I can say that sometimes the bar of vaccine knowledge is very low, but the opportunities to engage with it are often limited and costly. Just to give you one example, we had a meeting in Hackney where the Orthodox Jewish community invited a consultant in health protection, who sat there and just engaged with families and answered questions. But that is a rare opportunity, and if we at the London School had not paid for it, would it have happened? How can we keep building on that?

Danny Beales

I suppose that goes directly to the point that it is not just about access. In that community, you could make vaccines available in every single GP surgery with open access: a walk-in service. But unless you are doing active work to reach out to the community to start talking to them about vaccines, you will not build the confidence that people need to use the walk-in service. Clearly, it is not just about access points; it is about actively doing that work of engaging with people, of talking to them about their thoughts about what might be in the vaccine, whether it is halal or contains meat products, or if there are other potential issues.

Dr Kasstan-Dabush

Often the convenience and the confidence come together. What we often see is that short-term funding cycles limit the ability to advance them together, which mean that projects start then stop. You might get some measures of progress, but then you have attrition once the funding stops, and that is the problem. It is the ability to sustain what good work is done at community level with local authorities and primary care networks.

Danny Beales

The vaccine strategy is quite silent on these issues about hesitancy really; again, it just talks about access. Do you think that is a problem? Should the strategy be talking about the things we are discussing around hesitancy and misinformation?

Dr Kasstan-Dabush

The strategy talks about tailoring the core offer, does it not? We can talk more holistically about the programme delivery, the community engagement and how they come together, so my answer is that it is there. But Greg, you were going to comment.

Greg Fell

Just to come back briefly, yes, there is a mis- and disinformation thing, but there is also a thing about speaking with and through community and faith leaders, which may or may not be overtly about mis- and disinformation; it may just be about answering people’s legitimate questions. That is simply a resourcing issue, and one of the lessons of doing this stuff well is when we resource interventions such as the one that Ben articulated, which the London School paid for. To really get into the guts of speaking through and with our community leaders, we can address some of the reasons why people are possibly not acting on mis- and disinformation, but they are just complacent, and there is something about complacency there as well.

Danny Beales

That is fair to say. I could certainly talk about complacency when looking at the effect of the strategy over the last few years. Finally, you talked about malign actors, Greg. Do you think people who are actively promoting false information about vaccines should be held responsible for the implications that has?

Greg Fell

Yes. We have all seen it: it is on social media all the time, and it shapes people’s views and opinions. It shapes policymakers’ views and opinions just as it shapes patients’ or citizens’ views and opinions. But I do not know how to do the accountability on that one.

Dr Aggarwal

I agree absolutely with what has been said with regard to vaccines, that misinformation is not the only factor and is probably not the major factor. We see misinformation very broadly across medicines, vaccines and medical devices, and we know from research we have done that 80% of GPs will see a patient coming in once a week with some kind of misinformation about a medically related topic. But there are already laws that prohibit individuals and organisations from what is termed promoting medicines and vaccines, and that would include misinformation, so from a legal framework perspective those laws and powers already exist. But when there is so much misinformation in the social media space, actually implementing any action against individuals is practically really hard to do.

Danny Beales

Should social media companies be held responsible for moderating incorrect health information about things like vaccines?

Dr Aggarwal

I would not be in a position to comment with regard to what social media companies should or should not be doing. We know patient organisations have been engaging with the likes of Google. You get Google AI summaries on medical topics now, and it has been engaging to try to improve the accuracy of some of that, with some success. So I know there is active engagement going on at the moment.

Chair

You were nodding, Ben. Do you agree?

Dr Kasstan-Dabush

Just to go back, during the covid-19 pandemic and the vaccination programme, we saw social media companies use little messages saying, “Please direct to the World Health Organisation for information on vaccination.” I never saw any evaluation of how helpful or pragmatic that was, but it is a sign of the responsibility that we can bring to advancing routine childhood vaccination programmes. I do not see what harm it does.

Gregory Stafford

I am moving on to talk about the access side. First, Mr McCaul, how effectively is the NHS using the capacity of community pharmacies to deliver vaccinations? What could be done to enable pharmacies to expand that role?

Fin McCaul

They are using it quite well at the minute, but we could be doing lots more. Going back to access in deprived areas, there has been a huge uptake of both flu and covid vaccinations in BAME communities in deprived areas through community pharmacy. This year, we have taken on the two to three-year-olds, but when we look at all the other children, and at RSV, pneumonia and shingles—in terms of helping patients protect themselves and be a prevention centre—there is a massive gap. To give an example, we used to work with the local school immunisation team, and in half-term week we would give them some resources in our pharmacy to enable the school kids to come in. We could not do it on their behalf; they had to bring in their team to do the vaccinations. If a child missed that day, they did not get done, despite the fact that all my healthcare professionals were there and able to support those patients. Access is a massive benefit, and it has probably been the bigger problem, but I agree that there is hesitancy around misinformation as well.

Gregory Stafford

If someone had a magic wand or a bucketload of money, neither of which is true, but just imagine if it were—

Greg Fell

No one in this building has given me a bucket of money.

Gregory Stafford

What would you like to see that would enable community pharmacies to expand and be able to deliver more of a vaccine programme?

Fin McCaul

If you look at it from a patient perspective, a community pharmacy is more accessible than most other vaccination centres. Patients come to us more often than any other healthcare professional and, on average, 12 times more often than a GP, so for me it makes sense. The community pharmacy has delivered flu vaccines for 10 years. We delivered over 40 million covid vaccines, and we are respected and trusted in this area. I would like to see all vaccinations being moved to community pharmacy as a core resource centre. That then enables the shift in primary care that we are talking about, freeing up space in GP surgeries and moving secondary care work into primary care.

Gregory Stafford

Greg, I will come to you in a second. Fin, do you have any reflections on what has happened this winter in terms of vaccinations, from your point of view?

Fin McCaul

I will try to be polite.

Gregory Stafford

No, you do not have to be polite.

Fin McCaul

I would say it was absolute chaos. There was total misinformation around which patient groups could access covid vaccinations. We set up a team of three people to vaccinate for the first two weeks, with a guide to lead those people through. I ended up putting in a team of six people just to deal with the abuse, the complaints and the misinformation of patients who were expecting to be vaccinated because they have had it for the last five years but were not allowed to be vaccinated this winter. From that, there are some learnings that we need to take forward in terms of clear, concise information in a timely manner, as well as booking systems not allowing people to book when they are not eligible.

Gregory Stafford

Whose responsibility—I will not go as far as saying blame—was it that this information was not there? Is it NHS England? Is it the Department of Health and Social Care? Is it Ministers? Who needs to make that decision? Who needs to take responsibility for that?

Fin McCaul

Everybody played a part in it, if we look at it as a lack of communication with patients. We went to healthcare professionals and said, “This is the group of people.” But we never went to patients and said, “You are not able to do it this year.” The digital platforms were not enabled to prevent people from booking, and NHS England was slow to react to the messaging, but it did get there in time.

Greg Fell

I broadly agree, but I would be very careful about breaking the basic delivery system of vaccination, which has been general practice for decades. It has served us very well, notwithstanding some of the current issues. There is an issue of market fragmentation and how that all comes together. Undoubtedly, delivering through community pharmacies gives access and convenience: I get my flu jab through my community pharmacy, so that is a thing. There is something about population coverage, and we neglect high-risk populations at our peril. Who can see what data so that we know who to chase proactively, who to call or recall on, so that we are not needlessly chasing people who have already been vaccinated or offered 15 different times? The co-ordination of that for a given population at a defined level of geography. I am local by default, so I always default to the local authority areas, because that pays my salary; the relational stuff works quite well at that level.

Gregory Stafford

Moving on—this is adjacent, in terms of access—during covid, we obviously set up vaccination centres absolutely everywhere: in schools, playgrounds, parks, car parks, buses and so on. Is that a model that could be used for delivering annual winter vaccinations? I am not talking about regular vaccines, but when we have a spike—as we often do over winter—we need to vaccinate people. Would that approach work, and would it help to reach some of the underserved communities that you have been mentioning?

Greg Fell

I remember it well. I never thought I would be a car park monitor, as I was for a brief period during that time. It was a model that served us well during the middle of the pandemic; I am not sure that it would serve as well in peacetime, even during a spike or an outbreak in a difficult flu year. We do that kind of thing in the context of measles outbreaks and the like, when it is basically all hands to the pump to put a stop to the outbreak. But in the context of routine vaccination, even in a difficult year, the administrative effort of doing that and the resource needed is probably not worth the win. I will come back to making sure that the basic delivery system, including all the points of access, is well connected and co-ordinated. I would not set it up in a car park or a bus-type territory.

Gregory Stafford

I will press you on that slightly. Okay, I can see the argument for not necessarily having a pop-up in a car park, but is there not something about trying to get the vaccine programme as close to those people who are going to need it, especially in underserved areas? I am not trying to invent something, but could a bus not go to an underserved population and deal with the vaccinations there? Would that not be a useful thing? I accept it would not be a mass rollover of every car park everywhere, but targeted interventions and being a little more flexible than we were before.

Fin McCaul

We have 6,000 general practices; we have 10,000 pharmacies. If we use those people properly, you will have that coverage. The challenge we have is that the whole investment in primary care has left us very at risk. So rather than reinvent the wheel—I set up the vaccine centres in the middle of covid, and we do not want to go back to that—we want to invest in the infrastructure for the whole of primary care and be really clear with patients on what they need to do.

Dr Kasstan-Dabush

Just very briefly, to engage Fin on this point. I have read reports of a greater risk of pharmacies closing in areas of higher deprivation. That there will be a disproportionate impact on areas where coverage is already lower is what really concerns me. Fin, I wonder if you could comment a little more on that.

Fin McCaul

We are getting into the whole of primary care sustainability, and particularly community pharmacy. Notwithstanding what Greg has said, why would I like pharmacies to be a core vaccination and prevention agenda delivery solution? Because it helps with our sustainability, but it also helps with the long-term view of where primary care is going. If we are able to get that commitment through the strategy as well as the investment, we will get that sustainability on a two-tier front.

Gregory Stafford

Forgive me, Dr Kasstan-Dabush, I was expecting you to talk to me about your evidence to the covid-19 inquiry, where essentially you said that the vaccine rollout via outreach clinics would address inequalities of access. I seem to remember that was your evidence. Are you rolling back on that?

Dr Kasstan-Dabush

No. In a universal vaccination programme that needs to be delivered at rapid pace, it absolutely does work. In the routine programme, I do not know if it applies in exactly the same way. I do not think it is stepping back on that evidence, it is understanding where it applies and where it does not, again because of the administrative and resource cost that that will involve.

Josh Fenton-Glynn

I quickly want to pick up on something Greg said in the last set of questions before I go on to my substantial questions. You said that the broader rollout would not be appropriate in peacetime, and I understand that. In my authority we used a large car park, and having people getting vaccinated and tested in a car park was all a bit weird. But there were elements of it, particularly looking at hard-to-reach groups, that I look back on with great pride and think we should do better. One of the examples I will give is that our vaccine bus went to the mosques. Actually, when we did that, we also had advocates and people delivering the vaccines from the community. Why are we not using those lessons better, from a public health perspective?

Greg Fell

Resourcing. It was very well resourced during that period, to the credit of the Government of the day, and did not speak to the underlying drivers that Fin has eloquently talked of, about pressure within community pharmacy and the same within general practice. Those are real things, and layering on buses when not dealing with the fundamentals is somewhat problematic for me. I am absolutely not against taking vaccines to where people are, and I agree with you that taking vaccines, whether it is on a bus or some other form of transport, to a mosque is a good thing because that is a way to speak with and through community and faith leaders in a trusted context and setting. I may add family hubs, with regard to children’s vaccinations, into the mix. But I would never err away from the basics of the delivery system, getting that sorted and doing the dull stuff well consistently over decades. We definitely should be working with and through our communities and be taking vaccines to people and making it easy and accessible, but not neglecting my point about the co-ordination of the whole system so that folk do not get confused, which certainly happens.

Josh Fenton-Glynn

I would say that the Venn diagram of church attenders and people who should be taking their flu vaccine is probably quite a closed circle, so there are a lot of those kinds of things. I can see you want to get in, Fin, but I have questions in another area, so I was just following up. I am really sorry. UKHSA recommended that professionals across the healthcare system should make use of every opportunity to offer vaccinations. Building on this, how can we be more opportunistic in how we deliver vaccines? I will go to Fin here.

Fin McCaul

I am going to speak from the experience in our pharmacy. From about August onwards, we encourage our patients to book their vaccinations. From the day the vaccines arrive, we are encouraging them—

Josh Fenton-Glynn

Can I interrupt you quickly? So when someone comes to get something else, you say, “Have you booked your vaccines yet?” Or do you just have a sign saying, “We offer the flu jab”?

Fin McCaul

We email them, we text them, we put a slip in their prescription bag and we speak to them about it. That is for flu and covid at the minute. We have a disparity in that the covid vaccination system did not open until September this year, whereas next year I am hoping it is going to open earlier. The covid system and the flu system are two totally different systems, so it becomes challenging from that perspective. Plus I can only do the cohorts that I am enabled to do. I cannot do the children, and I cannot do workers because they are the employer’s responsibility.

Josh Fenton-Glynn

What structural changes do you think we need for primary care to make opportunistic vaccination a bit more routine? In some ways, that builds on what you were saying about the resource we currently have in primary care.

Fin McCaul

To talk about those hard-to-reach groups, I am really concerned that there are now no additional payments for the housebound, or to go out to the mosques and churches, so we are reliant on the patients coming to us. Legislation is in place to enable it, but it is just a payment model because there is an additional workload on that side of it. Equity and payment is a different conversation, though.

Josh Fenton-Glynn

So more money to pharmacists?

Fin McCaul

No, to the system, so that everybody in primary care is in the same boat. It does not matter. This is not about pharmacists.

Greg Fell

The same: it is a resourcing issue for primary care generally. It is a broad church, as Fin said. I would be looking very carefully at the incentives within the Quality and Outcomes Framework for childhood vaccinations. A flat rate of payments where you do not get paid if you do not meet the threshold target—I think it is 80%—disincentivises practices in poorer parts of our cities to try to meet the target. That leads to systemic inequality. That needs some really careful thought, and there is a basic issue in resourcing within primary care. On being opportunistic, making every contact count, I had an interesting conversation on this with paediatricians a few weeks ago. They were saying, “Should we be having opportunistic conversations in A&E?” To which I said, “No, probably not. It is too chaotic an environment. Out-patients, probably.”

Josh Fenton-Glynn

I am going to move on from that very quickly. The vaccine strategy sets out an ambition to train and deploy a wider set of professionals to deliver vaccines. I would guess that also includes people such as health visitors, and so forth. What do we need to deliver that ambition?

Greg Fell

There is a resourcing issue. I will pick on health visitors, as they are amazing. I am not against health visitors vaccinating, and historically they have done it, but we need to resource them to do it if we want to do that. Otherwise it means they will be doing less of something else that is also pretty important, so it is actually a zero-sum game. Health visitors vaccinating opportunistically is administratively really difficult. You quickly get into logistics, cold chain and those kinds of things, and it probably becomes not worth the effort. Health visitors vaccinating cohorts in settings? Maybe. Again, it goes back to my point about being careful about disrupting the basic delivery system. But were you to press me, and I think you will, I would have my health visitors doing a lot more on answering people’s questions, because they are amazing at it. That is obviously with children—

Josh Fenton-Glynn

A pilot started in January this year, and part of it is teaching them to have tricky conversations, so it is clearly something that is in train.

Dr Aggarwal

I have a quick point on the opportunistic delivery approach. If that is going to happen safely and effectively, accurate and accessible patient data and records are one of the really important aspects. You need to be able to view and update your records to avoid duplication and to make sure it is recorded.

Chair

We are going to come to this.

Dr Kasstan-Dabush

With the burden of vaccine programme delivery being very much on primary care, there are ways that they can be supported in secondary care settings. For example, during the covid-19 programme, consultants and specialist care pathways were routinely recommending influenza vaccination to people in eligible risk groups. But when we asked if they would do that for influenza, they did not. So they did not continue that practice from covid into the seasonal influenza programme, and it is a missed opportunity.

Josh Fenton-Glynn

If I keep talking, the Chair will have me.

Chair

She will.

Dr Cooper

Moving on to doing the dull stuff well, which is always excellent, we are going to talk about data. Can I take you all back to the pandemic? It was always a joyous time, but we did some really good work during the pandemic. There is nothing like a disaster or a crisis to make people work really well. The King’s Fund actually said that the NHS had never used so much data so powerfully to operationalise a programme. My question to you, starting with Greg and seeing how we go, is where did those learnings around data collection, surveillance and effective utilisation go? Where have they gone into our vaccination programmes? Are they still there? What is happening?

Greg Fell

They have not gone far. I try to avoid looking back on the pandemic if at all possible, but I will briefly.

Dr Cooper

That might be a mistake that you should reflect on.

Greg Fell

I will be really clear on this. As director of public health in Sheffield, I did not have access to line-listed data until month five of the worst public health emergency ever, which I was responsible for managing in Sheffield. That was not okay, and it took an awfully long time to get line-listed data for vaccination availability as well. When we did, we could target our interventions very precisely. It helped enormously, and it helped me to give assurance to the Government, in my case local government in Sheffield, that the city was doing broadly the right thing with regard to managing the response. When we did get the data, in all that time, there was not a single data breach—we can be trusted with that data. This is largely about trust and risk appetite, rather than the technical stuff around access to data. Data access is poor now.

Dr Cooper

Just to make the link, I appreciate that reflecting on the pandemic is difficult but I think we should. During the pandemic, you were there and had the data, as you say, by month five—shame that it took until month five—and you were able to target all the issues around inequity, inequality, targeting harder-to-reach people, which is all good. Why, when the pandemic went away, thank goodness, did we not keep those learnings and transfer them to our vaccination system?

Greg Fell

I do not know. That is my short answer.

Dr Cooper

Okay. Thank you for your honesty, Greg. Does anybody know?

Greg Fell

Just one very quick point. It is fair to say that, as DPH in Sheffield, I do not have day-to-day responsibility for delivering the vaccination system. I have responsibility for mopping up the mess, such as managing a measles outbreak when it happens, but access to the data is really important. We have half-decent practice-level data, but I would want to get more granular if we really wanted to get into focusing and targeting.

Dr Cooper

Would anybody else like to comment on data sharing and learnings from the pandemic?

Fin McCaul

It is going to be the obvious, but we need it; it is absolutely critical. There was a Journal of Public Health study, “Implementing targeted vaccination activities to address inequalities in vaccination”, which came out in 2025. Progress towards local data availability has been lost. Vaccination of frontline healthcare and social workers—that is a backward step. National versus local has been a backward step, as has national communication. All lost in that report. It is a lot of good reading.

Dr Cooper

It is slightly concerning, is it not? Because without data and without being able to have good surveillance systems, we really are slightly blind, I would say. Ben, you are at LSHTM, are you not? Do you have any thoughts on WHO data and surveillance and how we are utilising that to track immunisation rates in the UK, and perhaps understanding where the trends might go for diseases?

Dr Kasstan-Dabush

I do not feel able to comment on that right now, but I can certainly follow up with written evidence.

Dr Cooper

That would be really useful, thank you. Just one more query on data around the Child Health Information Systems. Greg, the ADPH has said that there should be a national immunisation data portal that is accessible to local authorities, integrated care boards and providers that can be used for assurance and to inform and drive vaccination uptake. Presumably that would make your job a whole lot easier.

Greg Fell

I would still agree. I stand by that.

Dr Cooper

Excellent, and has DHSC given you any assurances that it might be coming forward?

Greg Fell

Not to date, but you may wish to ask my colleagues afterwards.

Dr Cooper

Excellent. We definitely will. Just moving on quickly to inequalities and inequities; we have talked quite a lot about this, so I just want to look at a strategic level on the UKHSA’s immunisation equity strategy. Do you think the strategy identifies the right actions around the inequity issues, and are there any gaps in that strategy? Would one of you like to talk to that? Presumably you know what the strategy is.

Dr Kasstan-Dabush

The strategy shows that vaccination is a universal mandate, but it has a particular commitment to equitable delivery strategies as well, and that is a real strength. It points to, for example, the World Health Organisation’s tailoring immunisation programme. There are case studies done in Hackney on integrating behavioural insights into policy and practice. However, one of the limitations is that we often do not have a clear idea of the funding that is made available to implement the recommendations, and the responsibility and delegation of responsibility to oversee implementation. So it is great to use these tools, but they really need to be complemented by a commitment to action.

Greg Fell

I agree. It is actually pretty helpful.

Dr Cooper

In what sense is it helpful?

Greg Fell

It says broadly the right things in the right way, but it is a separate thing. Where I would want to get to is a single national strategy for the population of the country, as opposed to different agency strategies. Certainly that would be my push for my population in Sheffield, and I think most DPHs would say the same thing. As Ben has alluded to, there is a reclarification of who has what responsibility and who has what accountabilities. I may stand corrected on this, but I do not think the Yorkshire strategy talks to the fundamental inequity within the primary care delivery system, both the basics of primary care and the modified Carr-Hill formula that basically set up inequity in primary care resourcing. But there are also the inequity incentives created by childhood vaccination being in the QOF, with a flat rate of payment, so that you do not get paid if you do not meet the targets. That sets up inequity, and we could speak more strongly to that. Admittedly that may not be in Yorkshire’s bailiwick, as it is in the system’s bailiwick, but if we are having one strategy, we should be talking to some of the basic drivers.

Dr Cooper

When you talk about who is responsible for what, do you have thoughts on who should be responsible for what within this strategy?

Greg Fell

I suppose there is a strategy and policy aspect that is largely a DHSC thing: there is surveillance, commissioning, delivery, outbreaks. I am not sure that a single point of accountability is possible. I will not speak for national level here, because it is not my bailiwick; I will speak for local. The accountability is mixed across a number of different actors, and I guess I am the person who tries to pull it all together, but my escalation routes are actually quite weak. We bring an annual report on health protection to our health and wellbeing board, which is the point of reference for all things health and wellbeing in Sheffield, and every DPH will broadly be the same. Each year, we comment fairly strongly on vaccination, but I have fairly weak escalation points.

Dr Cooper

Where would you want to escalate it to?

Greg Fell

On vaccine delivery, I would want to escalate it to the ICB, which is the responsible commissioner.

Dr Cooper

Is that simply not a function of the health and wellbeing board?

Greg Fell

I cannot tell, as I have no authority. Neither I as the DPH nor the health and wellbeing board, which is co-chaired by the NHS and local government—a clinician and a councillor respectively—have the authority to tell the ICB what it should or should not do. Health and wellbeing boards are not decision-making bodies; they are partnership bodies. They do not have decision-making authority granted to them by either of their parents, the ICB or the council.

Dr Cooper

No, and it is a fair point; we are getting into structural issues, which we have discussed before. We asked this when our colleagues from DHSC came along. Do you think the DPH role should be a mandatory role on the ICB?

Greg Fell

Broadly, yes.

Dr Cooper

But it is not at the moment?

Greg Fell

But geography will be a problem. I can speak with alacrity for me. There are four local authorities within South Yorkshire ICB, and I do not have any authority to speak for Barnsley, Rotherham and Doncaster. It is the leaders of Barnsley, Doncaster, Rotherham and Sheffield who make decisions, so there are some issues to attend to there.

Dr Cooper

There is an elected role as well. Just to be clear, at the moment you are taking your vaccination reports to the health and wellbeing board, and there is no specific mandate for the health and wellbeing board to take it to the ICB to look at the structural issues?

Greg Fell

Yes.

Joe Robertson

I will direct this question to the ABPI, which is probably most relevant. Can I ask what the process for producing the annual flu vaccinations looks like from the industry’s perspective? What are the key challenges that are faced, and what is the scope for accelerating the process?

Dr Aggarwal

The annual process for producing flu vaccines is very well established. Essentially, there is a process for the northern hemisphere and southern hemisphere. For us in the northern hemisphere, the process kicks off with the WHO’s global influenza surveillance and response system. It convenes a group of public health organisations, scientists and laboratories in February who, over the previous year, have been monitoring the various influenza strains in circulation. That WHO body will advise in February on what strains are most appropriate for the coming winter season. A process then kicks off with engagement with industry, and industry will start to produce the flu vaccinations using various technologies: egg-based, cell-based, recombinant vaccines. Those vaccines will then be approved by the regulators in the respective countries—the MHRA in our case—which will be looking at the vaccine in terms of quality, safety, potency and stability, and it will eventually be rolled out in the winter season. To summarise, the WHO does a kind of strain selection in conjunction with public health bodies around the world, the MHRA does the approval and then it is rolled out by the NHS. JCVI has a really important function the previous year, when it decides eligibility, so which population should get what vaccine.

Joe Robertson

Looking at potential for accelerating that process, or challenges within that process, do you have any views around that? There have been things spoken about by others in terms of under-investment in medicines generally, the UK’s branded medicines levy, foreign direct investment falling, capacity issues within the MHRA and lack of transparency. Are those things you recognise? Is there anything else that could be done or unlocked in order to speed up that process?

Dr Aggarwal

With regard to vaccines specifically, and influenza vaccines, the previous season’s supply has been pretty stable. There have been previous seasons where there have been shortages, and sometimes those shortages arise because there is a delay to the WHO process of advising on which strains of influenza A and B should be used. There have been manufacturing delays or manufacturing issues in the past where a whole batch or batches had to be discarded and started again. There can be local supply challenges, where generally speaking you do not have stock where you need it, so you get clustering of stock in some areas and less stock in others. Those are some of the challenges that can arise, and have arisen in the past, but generally speaking I would say that, last season, the influenza vaccination supply was actually pretty good.

Joe Robertson

I have taken the premise that it would be beneficial to have the flu vaccination available a bit earlier, and that having it early is a good thing. Would anyone on the panel like to comment on that basic assumption, that it would help uptake if the flu vaccine were available earlier?

Dr Aggarwal

In terms of when to deploy the vaccine, generally speaking, for the elderly the decision is to deploy the flu vaccine as close to the start of the season as possible, because there is a recognition that effectiveness wanes over time. That matters less for children or for pregnant women: they are generally younger and have a much better immune response, so you do not have to time it so close to the start of the flu season. It is also important to bear in mind that flu and covid vaccines tend to be given around the time the season starts, but there are other vaccinations relevant to winter bugs—thinking about pneumococcal or RSV vaccinations—which can be given at different times of the year, but they are really important in terms of that winter coverage.

Joe Robertson

Thinking more widely about taking new vaccines from early research to NHS deployment—not only flu vaccines—are there any system changes? You spoke about specific issues that can arise with, say, the flu vaccination, and you referred to the previous season, but are there any system changes that would most effectively speed up development, approval and deployment of vaccines generally?

Dr Aggarwal

The vaccine pipeline is actually quite rich. If we look at an organisation called Vaccines Europe, it does a pipeline review every year. There are 91 candidates currently in development, and about 40% of those are for diseases for which there is no current vaccination. In terms of creating the right environment to support both the development and deployment of vaccines, clearly having the right policy environment is really important. There needs to be sustained political will, strong partnerships and a policy framework that enables innovation, supports access and really takes that full life course approach to vaccination; it is not just about childhood, it is all the way through adulthood to the elderly. The role of public investment and research capability is really important. We have some real strengths in vaccine research in this country across Liverpool, Oxford, London, Cambridge and Bristol. We also have excellence in terms of our surveillance systems. UKHSA has a really strong surveillance system, and that helps us to identify priorities and the disease burden. We are really strong from a regulatory standpoint as well. With its expertise, the MHRA plays a key role in that WHO February meeting. I guess industry is fundamentally looking for confidence that there is a viable route for new vaccines to be produced and a viable route to patients and, once they are licensed and developed, that they will reach the public. That requires quite a robust health technology assessment, which is obviously carried out by the JCVI. We would really like to see improved transparency and engagement along that whole JCVI engagement and access pathway. There is scope to improve the scientific exchange that happens with the JCVI on that, as well as understanding, from its perspective, the factors it uses to influence what vaccines it is going to recommend. With chickenpox, we know it looked at the productivity impact on parents, and with the HPV vaccine for boys, at issues of equity. We would really like to work with it better, in a more transparent, constructive way.

Joe Robertson

I will finish by probing on the UK-US pharmaceutical deal. It seems to me that the health economics are fairly straightforward, but if the plan is to spend more money on high-cost innovative medicine, it will surely have a negative impact, with less money to spend on more routine, bread-and-butter, albeit life-saving, interventions. Do you agree with that assertion? Do you have any concerns around that?

Dr Aggarwal

In terms of the UK-US agreement, the exact source of the funding has not been clarified, but the Government have confirmed that the increase will not reduce funding for other NHS services. So the money that has been committed would not otherwise have been used to fund NHS services. When it comes to this issue of funding, it is important to note that it is very much not a zero-sum game. Medicines play a vital role in treating patients, preventing disease progression, easing the burden on the NHS in many ways, and helping to drive wider socioeconomic gains. Without these commitments, we spend much less on medicines than many other countries. The NHS budget since 2014 has increased by 45% in real terms, and the spend on innovative medicines has fallen by about 10% in real terms. When we have such a massive problem with inactivity due to ill health, we know it is a massive drag on the economy. We know that, in 2022, it was estimated to have cost us anywhere between £127 billion and £188 billion a year. Sickness alone resulted in £56 billion of losses due to absences from work. Medicines and vaccines are not the only part of this, but they are an essential part of the solution.

Joe Robertson

You started by referring to the Government committing more money, although you do not necessarily know where the source is; I do not think they have announced it yet. That indicates to me that there is an acknowledgement that, at least in the short term, more money is needed to meet the arrangements of the deal, rather than it being taken from elsewhere.

Dr Aggarwal

One really important aspect of the deal is the change to NICE thresholds, for example: innovative medicines do not affect vaccines. Importantly, that does not affect current medicines; it is only going to apply to new medicines coming down the track. The Government have committed to increasing the proportion of spend on medicines from 0.3% to 0.6% of GDP, but that is over a very phased 10-year period. So there is an acknowledgement that, yes, we need to reverse this disinvestment in medicines that has been happening over the past decade or more, but that needs to be done at a measured pace so as not to introduce undue burden on budgets.

Chair

Thank you very much. We will stop there. Thank you all for your time. Examination of witnesses

Witnesses

David Lamberti, Dr Mary Ramsay, Michelle Kane and Annie Traynor.

Chair

The job of panel 1 was to give us the lie of the land, and the job of panel 2 is to help us work out how to improve it. Can we please start with introductions, as per the last panel?

Annie Traynor

I am head of immunisation and screening at Leicester, Leicestershire and Rutland ICB.

Michelle Kane

I am director of vaccination and screening for NHS England.

Dr Ramsay

I am director of public health programmes at the UK Health Security Agency.

David Lamberti

I am the director for health protection and public health systems at the Department of Health and Social Care.

Danny Beales

This might be for Michelle and David. I am going to ask some questions about planning guidance and the vaccine strategy. Three years on from its development, how does performance compare with what was expected in the strategy?

David Lamberti

The strategy is a few years old now. The Government’s view is that the rates are not where we want them to be. We run quite a strong programme across the country. It is a good offer. It protects against a range of diseases, but the rates are not where we need them to be. We are active on a number of fronts. This morning you have been discussing access, information and so on, but the rates are not where we need them to be at the moment.

Danny Beales

How does it compare with what the strategy envisaged? Are we on target or off target?

Michelle Kane

It is a really great question. One thing that is probably worth acknowledging is that this is on the back of a decade of declining uptake. All of us in this room today are committed to doing as much as we can to improve vaccination rates, particularly in young children. It is not going to turn around overnight. In terms of your question, as to what we have done—

Danny Beales

Are we on target or off target compared with what the strategy envisaged?

Michelle Kane

We are making progress.

Danny Beales

So on target?

Michelle Kane

We are making progress.

Chair

Was there a target? Can you just answer the question?

Michelle Kane

There was not a target.

Chair

There was not a target, so we do not know.

Michelle Kane

There was not a target. The ambition was around halting the decline and realising improvement across vaccination.

Danny Beales

Have we done that? Are we halting the decline, or are rates still declining?

Michelle Kane

It is a mixed bag, actually. If we start—

Danny Beales

Some yes, some no, basically?

Michelle Kane

Exactly.

Danny Beales

If this is not failure, what would failure look like?

Michelle Kane

It would be much of the same or continued decline, but Mary will probably have a better view of what you could expect from a public health point of view.

Dr Ramsay

When you compare it with previous problems we have had in vaccinations, some have been much more dramatic. It is not as bad as it could have been, but definitely—

Danny Beales

That is not very inspiring: it is not as bad as it could have been.

Dr Ramsay

No, definitely not. I would like to have seen it stabilise by now at least, which it has not.

Danny Beales

As we are not confident that we are on track, and as we are disappointed, should we review the strategy? Is new impetus needed?

David Lamberti

There are two different things. There are the things we deliver on the ground underneath the strategy: the changes we make to national systems and to the way things work locally. That is important in terms of improving the core of the system, reaching underserved communities and getting the rates up. We did not have a numerical forecast as a result of the strategy, so we cannot say that we are off track against the uptake forecast because the forecast is not there, but the rates are below what the WHO is recommending.

Danny Beales

That is my question. Should we have a new strategy that includes things like a numerical forecast and targets to aim towards, as well as other issues that we might want to include?

David Lamberti

Mary may be able to offer more than me. A determinative forecast is a difficult thing to produce and have certainty about because, if you try to make a numerical link between the activities and changes we might make and what will happen to the numbers, there is going to be a very wide range of uncertainty. We need to watch the numbers. We need to see them stabilise and then go up, and we need to deliver the changes on the ground.

Dr Ramsay

We have existing targets that are internationally defined. For example, we take the WHO target of 95%.

Danny Beales

They have been removed from planning guidance, and we do not have a timescale for them in the plan.

Dr Ramsay

Michelle can talk on that; it is perhaps a misinterpretation of the information.

Michelle Kane

We are talking about three things at once. In terms of the targets, these are well established. In MMR, for example, we have 95% uptake for herd immunity. Those targets have not changed.

Danny Beales

They were removed from the planning guidance.

Michelle Kane

They were removed from planning guidance but, thinking about the NHS as a whole across section 7A services, which are largely population-based vaccination and screening services, we have a section 7A agreement that is really clear. It is reviewed every year and it is basically—

Danny Beales

What effect has removal from the planning guidance had?

Annie Traynor

Would it be helpful for me to give an ICB perspective on those changes?

Danny Beales

Potentially, but could you answer my question? What effect has that had? Can you speak to that?

Annie Traynor

I do not think that removing the target in 2025-26 has had any impact. The national strategy—

Danny Beales

So the data has remained the same, and we have not seen any decline?

Annie Traynor

The national strategy was incredibly helpful to us in terms of defining this as a priority for our health system. We have had that in our health system since 2023. We then had a subsequent measles outbreak, which really shone a light on the issues around disparities in access and uptake. The national strategy has driven improvement. We are starting to see those green shoots, particularly in areas where we have low uptake. In Leicester city—

Danny Beales

I apologise, but time is quite tight. We are going to come on to ICBs. My colleague is going to ask about it. Since the removal from planning guidance, rates of vaccination have gone up. It has not had a negative effect. Is that your view nationally and in your area?

Annie Traynor

The change in planning guidance has not affected the direction of travel. We are seeing a small increase in the uptake of childhood vaccines, particularly MMR dose 2. What I would say about the planning guidance is that it is incredibly helpful if it sets priorities that align with this area because when resources are being allocated at a system level, if vaccination is in there, it will be prioritised in a way that it might not be if it is not mentioned in that guidance. If you were to ask me if it would be useful, going forward, I would say yes.

Danny Beales

You do not think it is had an effect, but it would be useful to have it in there?

Annie Traynor

We are already setting our direction. We know from the national strategy where we are headed, but it would ensure that a focus on the resources we need going forward is identified by our health system.

Danny Beales

It would help with local prioritisation. We have heard from ICBs that it has made no difference to rates. Michelle, is that your formal view? The data suggests there has been no further decline in vaccination levels since the removal of the target from planning guidance.

Michelle Kane

I would agree with what Annie has described. What is critical about what Annie said is focusing minds on that clear leadership and steer to the system that vaccination is everybody’s business.

Danny Beales

Do you think it would be helpful to have it back in the planning guidance for next year?

Michelle Kane

That will come as a Government response to your report. From my point of view, everybody on this panel today is committed to improving uptake across vaccination.

David Lamberti

I am aware the Committee has made a formal recommendation in its “First 1000 Days” report. Ministers will respond to that when they respond to the report. The planning guidance for next year is currently under consideration.

Danny Beales

David and Michelle, when will the UK reach the 95% level?

David Lamberti

We do not have a date and a target.

Danny Beales

When will we get back from the WHO our measles elimination status, which we lost this year? Do you have a target? Do you have any expectation?

David Lamberti

We do not have a target. We are acting across the piece to try to—

Danny Beales

Is it a problem that we do not know when we will get back our measles elimination status?

Dr Ramsay

Obviously, having high coverage is one of the main indicators of that, but it is not the only one. It is largely related to how many cases of measles you have. We had the large outbreak in 2024, which is why we lost it. We are now having lower levels, but we are still seeing the circulation of measles so, until we stop circulating measles, we are not going to get back to elimination. It is a retrospective process. Each year, we put in the data. Obviously, stopping circulation requires us to have high and sustained coverage, no pockets of low coverage, and it also depends on the international situation because we are affected a lot by measles coming into the—

Danny Beales

It is slightly worrying that we do not know when we will get back to high coverage rates, that we have no target for it and that it is not in a strategy.

Dr Ramsay

It is fair to say that we are all here because it is not as easy as it might sound. If you look historically, when we have had low coverage, it has often taken many years to get back. As Greg was saying, you have to get the basics right and work effectively.

Danny Beales

In terms of resourcing, from data we saw through a parliamentary question about the levels of spend from NHS England on vaccinations, it has fallen year on year over the last three or four years in both real and percentage terms. The previous panel talked about the need for resources for primary care, outreach, health visitors and a range of areas where resources could be used. Is it a problem that resourcing in real and percentage terms has fallen for vaccination year on year, based on what we have seen in terms of the performance of the strategy, the loss of elimination status and other challenges?

David Lamberti

I have not seen the detail of the NHS numbers you are describing. It is possible that some of that is the pandemic effect and the numbers were higher a while ago because we were in the covid period. Looking forward, Ministers will make decisions about spending for the NHS in the usual way, and there is a three-year settlement. There are a lot of different elements to the programme, so the issue for the system is how we use the resources effectively, both for the national programme and outreach.

Danny Beales

Should we expect, based on the situation you have just described, resources to be at a maintained or increased level?

David Lamberti

We have envelopes for the next three years, as I was describing. We have the budget that goes to Michelle for vaccination and screening, to be spent through NHS England. We also have a budget that goes to the Health Security Agency to buy the vaccines, which is set for the next three years, based on the forecast of what we will need. The challenge for the system is to use that money really well.

Danny Beales

Can you share any more information about that projection? Will the levels of financing in real terms, percentage terms, or both be maintained or increased over the next three years compared with the previous three, which have seen a decline every year?

Michelle Kane

I would refer you to Sir Jim Mackey’s response to the Public Accounts Committee on Monday. What Sir Jim quite clearly set out was from an NHS delivery perspective. We have a three-year settlement for vaccination delivery, supported by additional funds to improve access and inequalities, which the Committee touched on earlier this morning. That is sufficient to be able to deliver what we need to deliver over the three-year spending review.

Danny Beales

Can you write to the Committee to outline what you expect the budget for vaccinations to be going forward?

Michelle Kane

I am very happy to.

Ben Coleman

You have enough money to deliver what you need to deliver, yet we are failing on vaccines. That is not very reassuring. When you ask for money, you ask for it on the basis of arguments that you make. Has there been a cost-benefit analysis undertaken of the cost to the NHS of people not being vaccinated? Is there a cost-benefit analysis? For example, 10 years ago, there was a massive measles outbreak in one part of the country that cost £4 million to put right. More money spent on vaccination would have avoided it. Again and again, we see outbreaks due to a lack of vaccination. Has there been a cost-benefit analysis done on the cost of non-vaccination to the NHS?

Dr Ramsay

Not overall.

Ben Coleman

Not overall?

Dr Ramsay

Obviously, it is a very complex programme with lots of different elements. Every new vaccine has a cost to it.

Ben Coleman

Why has one not been done overall? You are arguing for money for three years for vaccination, and we have a failure in vaccination rates. They are poor and are going down. In my part of London, they fall every year. London is failing on vaccination generally—flu vaccination and others. We know that. Why have you not used the argument that it costs the NHS so much money when people are not vaccinated? To do that, you need to do an analysis of what it costs. Why have you not done that?

David Lamberti

If I may make two points. At the individual scheme level, when the schemes are assessed by the Joint Committee on Vaccines and Immunisation, there is a cost-effectiveness threshold that takes account of the costs to the health system that are avoided by the vaccination. So at the scheme level—

Ben Coleman

The health system what?

David Lamberti

Is avoided by having the vaccine programme. The individual schemes pass a test that they will save money for the institution.

Ben Coleman

Are you saying that, in having a vaccine programme which hits 65% against its 95% target, you analyse what that 65% means, or do you look and say, “If we got vaccination rates up, it would save the NHS this much money?” Could I just have a yes or no? Have you actually done a study? Is there a study?

David Lamberti

There is no study that does what you describe.

Ben Coleman

Then why do you not do one? You know there is a problem. We all know there is a problem. I am sounding quite irascible because I have been dealing, as so many of my colleagues have, with ICBs and others on vaccination for years. The first time I raised it in an ICB, a doctor said to me, “Well, some people do not like to get vaccinated,” as if that was an answer. There is a constant wall of failure. Why do you not make the argument for a proper study that says, “It costs so much money to the NHS, so we need more money for pharmacies to be able to run buses with local councils to take vaccinations to people”? Why do you not make that argument by doing a study?

Dr Ramsay

It is not a trivial thing. We can look at it again.

Ben Coleman

Will you look at it?

Dr Ramsay

I am very happy to try.

Ben Coleman

Will you come back to the Committee and say why you will or will not do a study? Whatever you say, and you are not saying anything particularly reassuring, vaccination is failing in this country and it seems to me that you are not doing two things that matter. First, making the economic argument effectively, and secondly, learning from covid. During those times, we did not say, “It is difficult to reach people.” As my colleague Greg talked about earlier, we just went out there with vaccines. We are not learning from it. What have you learned from it that we should be doing now? What do you think?

Michelle Kane

I have lots of views on this one as well, so thank you for the question. It is unfair to say that we have not learned from it, because we have. There are a couple of things. Let us go to the data, because there have been a lot of conversations around data. One thing that we rely on in terms of making sure we are maximising uptake, but most importantly to the points you were talking about, is focusing effort and energy where we have more challenges in terms of uptake and coverage. We need good-quality, timely data. Since the vaccination strategy was published in December 2023, we have done a couple of things to try to capture data—so capturing the event at the point of vaccination—and making sure that it is accurate and flows. Regardless of whether you have a vaccination in a community pharmacy, a GP practice, a school or somewhere else, that information about you and your vaccination event flows through to your GP record. Now that lends itself to a couple of things. It lends itself to more opportunistic vaccination. The earlier panel talked about learning lessons and vaccinating opportunistically. For example, if you turn up for a prescription, will you be offered a flu jab? We have the capability to do that now, and it is happening through a system called RAVS. Obviously, we like to shorten things in the NHS—it is the Record a Vaccination Service. It has also been introduced into maternity services across the country. What it has enabled us to see for the first time, in a way we have not been able to because the systems have not been joined up, is that the data has not been accurate. It had not been able to flow for maternal pertussis, which we have had a collective focus on with UKHSA colleagues, and there has been a shift from around 58% uptake to well over 72%.

Ben Coleman

I am of a certain age, so I go into my pharmacy for stuff, and no one ever says to me, “Have you had your flu jab?” I went and asked for a flu and covid jab, and I paid for them, but no one actually asked me. Your system, while admirable, does not flow right through yet. Can I ask about one particular aspect of jabs? Why can pharmacies not give MMR jabs?

Dr Ramsay

They can. There are—

Ben Coleman

When I raised it with the North West London integrated care board two years ago, I was told that it could not. We offered to do a pilot. It came back but was blocked higher up in the NHS.

Dr Ramsay

There are lots of different aspects to this. One element is the contractual element and how it competes with other contracts. One problem is that there are already contracts to give—

Ben Coleman

GPs might be annoyed if pharmacies can do it?

Dr Ramsay

That is an element. Local working together can get around that, which is obviously very important. The immunisation programme is now quite complex for children with lots of different vaccines, doses and products used at different ages.

Ben Coleman

I can see there are lots of problems. My question is: are you gripping this and trying to enable pharmacies to offer MMR vaccines? We have really bad rates on MMR vaccines.

Dr Ramsay

We are piloting some of those—

Ben Coleman

Everyone goes to a pharmacy. If you have a family, you are constantly going with your kid to a pharmacy.

Dr Ramsay

We are piloting some of those approaches, but it is really important that they are evaluated properly.

Ben Coleman

Where are you piloting them?

Dr Ramsay

I do not think we are doing MMR at the moment. We did do a lot during—

Ben Coleman

You are not piloting MMR?

Dr Ramsay

No, but we are piloting other vaccines.

Ben Coleman

I asked you about MMR.

Dr Ramsay

We did MMR in some areas during the outbreak a couple of years ago.

Ben Coleman

There were 43 pharmacies doing it in north-west England, and the funding for that ran out in April 2025. Nothing has happened since then. What was the learning from that?

Dr Ramsay

The learning was that you could use it in that campaign scenario. Whether it is the right thing to do in a routine scenario is a different question.

Ben Coleman

Are you assessing whether it is the right thing to do in a routine scenario?

Dr Ramsay

We offer other vaccines, so we are looking at other vaccines at the moment.

Ben Coleman

But MMR is really very serious: measles, mumps and rubella. We increasingly have outbreaks of measles. Is it not a priority for you to address this?

Annie Traynor

It is worth noting that there are a number of options for how people can access the MMR vaccine. As well as the routine offer through the GP and local health settings, it is also offered in schools. There is a catch-up programme for young people. If they have not had it through the routine offer, they can be caught up in schools.

Ben Coleman

Is it working? I keep coming back to the basic fact that it is not working well enough, which seems to underpin the entirety of the discussion. We should be looking at new ways, and that is why I am focusing on pharmacies. Everyone goes into one. You can stick up a big sign in five languages saying, “Your kid could get A, B, C, D. Why not have a jab?”

Dr Ramsay

The school offer is a really important one. It is something I would very much like to see being offered in schools. It is not happening routinely. Basically, there is a process of checking, but not all areas will necessarily then vaccinate. Vaccinating in schools is likely to be more successful than pharmacies in that age group, because parents are used to their children having vaccines.

Ben Coleman

Is it more successful than pharmacies? One of the worst meetings I was ever in with NHS experts was right at the beginning of covid when I, and all the other chairs of the health and wellbeing boards in London, sat around a table and they said, “Oh no, we are not going to do lockdowns because we do not think the British people would wear it.” How many people died before we did a lockdown? When you say, “We do not think,” is it based on evidence or is it based on chats with your mates?

Dr Ramsay

It is based on evidence, but maybe not specific to MMR. This is the problem: you cannot generalise from covid to MMR.

Ben Coleman

It is not based on evidence for MMR? Why are you not—

Dr Ramsay

Not specifically, but there is good evidence for other things such as flu. People who would have gone to general practice go to the pharmacy. The service was not set up properly to improve uptake, and there is quite good evidence of that. We are looking at it again. We are looking at RSV. We are looking at other providers, health visitors and so on.

Ben Coleman

I get that you are looking at other things. May I have a commitment from you that you will look at MMR, because that is a very serious issue and I do not think it is—

Chair

Yes or no is sufficient.

David Lamberti

We will take the question away and come back.

Andrew George

On the back of that, one of the Government’s three shifts over the last 18 months has been from sickness to prevention. Clearly, vaccination has to be up there. Annie, from your perspective—and I am sure you are in touch with your colleagues around the country—how prepared do you think ICBs are to take on the role? What support are you getting from NHS England and the Department?

Annie Traynor

We are absolutely ready. There may well be some variation across the country, but ICBs have known, since December 2023, that they would become the commissioners. Originally, we expected that to happen in 2025. We are on track and have been working towards our readiness for a number of years, almost to the point where we would have liked it sooner, to be honest. In terms of support, we are working closely with our regional NHS England team to plan how the transition will work. From 1 April this year, we will be working with our regional colleagues collaboratively on more of a co-commissioning approach so that we gain knowledge and insight into the contracts that we will inherit, some of the complexities in those providers, and some performance issues and concerns. The work that needs to carry on is in relation to the role of OPICs, so the offices of pan-ICB commissioning, which are part of the new governance arrangements under the NHS re-organisation. What will be very important for us, in terms of our capabilities, is ensuring that the roles that can be done once across the midlands region are secured and that they are identified to support vaccination programmes within OPICs.

Andrew George

One area you will be taking on, and this is really a question for others, is a system that is clearly failing. If you look at hospital admissions in respect of winter flu outbreaks, vaccination levels have clearly gone down over the last year. This year has been the worst on record as far as hospital admissions are concerned. That trajectory has been getting worse over the last few years. What action is going to be taken in terms of pushing that curve in the opposite direction?

Dr Ramsay

I would not say this year has been the worst on record in terms of flu admissions. This year, the flu season was earlier, so there was a lot of talk about it being really bad at a point in the year when it is not normally that bad, which is true, but it has not been worse overall. Flu varies year on year. We will not know formally until the end of the season, but it is within what we see. In fact, coverage in the flu programme has been largely the same, very similar to last year, or slightly better in some areas.

Andrew George

Flu vaccine take-up has fallen, has it not?

Dr Ramsay

Fractionally in some groups, but it is up in other groups. I would say it is very much the same as last year and still, in many areas, above pre-pandemic levels.

Andrew George

So the latest information you have on delivery is not clear. Presumably it is still being delivered now, even though it is late in the winter. Is that right?

Dr Ramsay

Yes. Flu is one of the areas where we have not seen this long-term trend. We have seen a long-term decline over many years in the childhood programme. Flu went up during covid. It is coming back again, but it is still higher than it was pre-pandemic across most groups.

Andrew George

Coming back to a question Ben asked earlier, in terms of quantifying the consequences of not vaccinating. Without question, certainly in the last five years of hospital admissions, the cost is greater to the taxpayer than it would be if your prevention and vaccination programmes were in place.

Dr Ramsay

We have done some work along those lines. We looked at what would have the biggest impact on admissions if you increased coverage in different age groups. It is actually the childhood programme that has the biggest influence. I am talking about the childhood flu programme, because it reduces transmission, has a really good herd effect and protects older people. The vaccine is much more effective in children.

Andrew George

The vaccination rate is very low in that area, about 40%.

Dr Ramsay

In schoolchildren, who have the biggest influence because they are the spreaders, it is over 50%. In primary schools, it is 55%. It has been climbing up a little, but it is an area of particular focus. School-age vaccination is a real focus for us.

David Lamberti

On admissions, as Mary was saying, the flu season started earlier. Its positivity and admissions were rising at a reasonably steep rate, equivalent to previous years when the peak had been really high. There was a point in December when, for that moment in the year, the admissions were higher than in previous years for a relatively short period.

Andrew George

Those figures in the first week of December are the ones I was looking at.

David Lamberti

The peak of admissions was around 14 December, and then they began to fall. There was a period in the autumn when everyone was very worried about the potential impact of the flu season. In the event, as Mary says, the numbers fell and turned shortly before Christmas, so there was a point when admissions were very high compared with previous years. The vaccination programme was probably quite instrumental in turning that around.

Andrew George

It relates to a wider question about the management of hospital beds, high occupancy levels and the fact that you can predict this. You may say that it has plateaued this year and not increased significantly, but the fact is that it has increased over the last five years. On that basis, when you have in excess of 95% to 96% bed occupancy, and certainly in my part of the world it is much higher than that, you are talking about stresses in the system that result in avoidable deaths.

David Lamberti

Yes, the system is operating under pressure each winter, as you observe. Any flu admissions add to that. The more flu admissions we can avoid, the better. The UKHSA’s analysis shows that during the previous winter, which is the last dataset we have, around 100,000 admissions were avoided via the flu programme. That is a valuable thing to do. A number of things were put in place this year by Michelle and her colleagues to try to improve flu uptake, partly for this reason.

Andrew George

Such as?

David Lamberti

The flu walk-in finder.

Michelle Kane

It is fair and accurate to say that we are in a better position this year than we were last year in terms of flu. Obviously, we set out to halt the decline, as we talked about previously, but also to improve on that position. Compared with a similar point last year, we are actually more than half a million flu vaccinations ahead of where we were. That is really important to recognise. As your questions are alluding to, Mr George, it is not as straightforward as vaccinate and save, which is where we are getting to. There are a couple of other things worth considering. One is the impact that the RSV vaccines had this year, which is really important to think about, particularly for newborn infants and older people. Since we started rolling it out in September 2024, we have had really good uptake. For those aged 75 to 79, the latest official publication shows a 66% uptake. We are expecting publication of an updated number shortly. Alongside that is the covid vaccination programme. From spring, we are extending RSV to offer it to the over-80s. To your point on the pressure on beds and people coming into hospital really unwell, while RSV is not a seasonal programme we see the impact it has in protecting people and keeping them well over the colder months.

Dr Ramsay

Expanding that programme will have a much bigger influence than, for example, a small increase in coverage for flu. Those are the kind of things we need to balance.

Chair

It is probably worth saying that this Committee is going to be looking specifically at corridor care, such is the crisis that we see. We are interested in these questions because vaccination can play a part. If you have more information about how different it is going to look next year and what part it will play in avoiding the crisis of corridor care, we would love to hear it.

Dr Cooper

I am going to stick with winter flu, because it is a regular occurrence. We can plan for it as well as we can for anything. I have some specifics I would like you to speak to. The first one is around schools and the programme rolled out across all schools to try to reduce flu transmission and get ahead of it before it gets going. I appreciate that the flu season this year started early, but could you please explain why the start date for schools to begin this programme varies so widely? For example, in my constituency there were schools that were literally just getting going with their programme a couple of weeks before Christmas. From a national strategic point of view, what is being done to make sure that, as soon as schools hit their September start date, the programme is being rolled out to the best of our ability?

Michelle Kane

As well as the start date, let us pick up on the end date because that is also important. It is a great question. On the back of JCVI recommendations, we can start the children’s flu programme, as well as vaccinating those who are pregnant, from 1 September, with others following from October.

Dr Cooper

Why is it not happening as standard across schools? What is the problem?

Michelle Kane

There are two things I would call out on that one. The green light and the get-go are dependent on when the vaccine lands in the system, and you have heard from colleagues about the manufacturing process. We normally expect it from the second week of September. From a national point of view, the system should be ready to start vaccinating in schools from 1 September, as soon as the vaccine lands.

Dr Cooper

I understand the idea, so why is it not happening?

Michelle Kane

Exactly. There is a lot of work to do in this space. I recognise there is variability across the country. There is variability of capacity within providers and the systems they use. There have historically been challenges around consent, in particular.

Dr Cooper

We were talking about those earlier, in relation to the accessibility of vaccines. Greg Fell referred to the letters in the school bag. You have a million things to do with your kids, so that needs to be thought about.

Michelle Kane

It needs to be thought about. On the back of the strategy, we have co-designed with system users, parents and practitioners an in-house system of managing vaccination services in schools, which again goes back to the point of care. Annie is using this in Leicestershire so can probably give you a better real-life example. In effect, it does three things. It makes it really easy for parents to consent by their phone. You can actually get a message that is readable, so you do not have to zoom in and zoom out. You can consent on your phone for your child to take up the offer of vaccination. That lends itself to efficiencies and safety, thinking about the administrators who support those services in being able to automatically cross-check consent with the class, set up the clinic and so on.

Dr Cooper

In the interests of time, it would be great if you could write to us on the plan. What I am saying is that it is February now and we have a few months to go until 1 September. How assured can I be as the MP for Worthing West, and can all my 600-odd colleagues be, that their schools are going to have a good, functioning flu prevention programme for students from 1 September, the second week of September, or whenever the vaccine lands? When we speak again next year, can we say, “Oh fantastic, all schools started the second week of September and finished by the end of November?” How assured are we that that is going to be the case?

Michelle Kane

As you have said yourself, we are still in the flu season. We are working through what it should look like, what it must look like, and what it needs to look like going into next year.

Dr Cooper

Let me be more salient: are we assured that, for the next flu season, which, let’s face it, is not far away, it is going to be in place? Are you going to be able to come back next year and tell me that it worked so much better and was finished by the end of November?

Chair

What is going to be different?

Michelle Kane

We are working really hard to make sure we are building huge improvements into those programmes. There is more that needs to be done.

Dr Cooper

So let us see if it actually comes forward.