Corrected oral evidence
Oral evidence, 23 March 2026.
Baroness Neuberger
In that particular endeavour, with all the extra capacity that you have provided, how was the take-up? What did it look like? Did people come forward to get the immunisation, or was that still very difficult?
Dudu Sher-Arami
It is still difficult, there is no doubt about it, but the good news is that we have had an increase in our MMR take-up. More MMRs were given in February than in any one month since 2018, though there still have not been the queues of people that I would have liked to have seen. There is a larger number of those people for whom it is MMR2, the second dose of MMR. Those are people who are accepting of vaccination but might have forgotten about it or it has been delayed for a reason. None the less, we have seen also a large uptick in MMR1s, as well as vaccination of people who are over five and some over-25 as well—people who have entirely missed the routine schedule for MMR vaccination. So, while there is some good news, we know that there are still many children and adults in the borough who do not have MMR vaccination.
Baroness Neuberger
I do not know if it is possible for you to give us some of that data but, if it were, that would be useful. It would only be an example, but it would be useful to see, if you add the capacity, who comes forward and roughly what they come forward for. That would be useful to frame things for us.
Dudu Sher-Arami
I am sure that Will and I can work on something.
Baroness Neuberger
That would be great. If it could be London-wide then that would be even more wonderful, but I do not know whether that is possible. I have a much more general question for all three of you, and this gives you the chance to lay out your pitch. What are the main barriers to developing effective core and outreach childhood vaccination services, and what would be the best ways of overcoming those barriers? I think that gives you a chance to say what needs to happen.
James Roach
The obvious part is always capacity and funding. That is because often we lose the battle around prioritisation. We need to be clear that we need to address these issues more routinely. The example just given from an Enfield perspective—being really flexible about the time and location where you can have a vaccination, and it does not have to be that particular GP but could be a GP within the primary care network because those GPs work together—is really important. Convenience, time and choice are key factors now, so that has been really helpful. We should be a bit more innovative about information provision and going outside the box. We looked at how we engage with our whole supply chain to provide expertise and assets. Within our region, we have worked with existing suppliers of vaccinations to provide particular information online or in print to look at innovative ways by which we can reach people. Reach is challenging, and people have a lot of public information that they have to transmit. The barriers have been traditional delivery structures, capacity and funding, and not being as innovative as we need to in getting that message out there. We have tried to address that by being flexible and using all our assets and means to do that. The key thing for vaccinations is that the assets are there in the community, but we have to be a lot more agile in using every one of those assets to improve uptake, collect information and support families and children.
Baroness Neuberger
Will, would you say something about schools as well? I would love at least one of you to talk about schools.
Will Huxter
I agree with all that. We have quite rigid structures about how we do things, and the way in which we contract with general practice sets up some rules about how things work that are not as flexible as what we would want to be able to do here. However, we do not have discretion to vary locally. We have talked about making sure that things are ongoing rather than stop-start. I have lost count of the number of times that feedback from communities has been, “You’re coming to us because you want us to get vaccinated. You need to come to us when it’s not about vaccination but is about other things as well”. We have touched a bit on people not being registered with GPs and not being connected with statutory services. One way forward is to put immunisation much more fairly and squarely in the context of neighbourhood health in the round. We are thinking about the homeless population from that particular standpoint, right the way through to other communities. The bit about flexibility is important. Schools are another area that has traditionally been quite cumbersome, even just at the consent level. Letters go out to parents, and then have we got the letters back? The staff are trying to run a busy school. Also, it is not just one vaccination programme; next term it will be HPV, and so on. There is a lot to deal with. In London we have re-procured our providers—the whole of north London is one provider and the whole of south London is another—in order to drive good systematic approaches to working with schools. Some schools or groups of schools have been resistant to having services brought in, and that is a difficult barrier because the route is not directly to the children; it is through the school. That is a particular challenge. I still think that schools are a great setting, though we also have to remember home schooling and kids who are not in school on the day that the vaccination team is in. There is a lot of mop-up that needs to be done.
Dudu Sher-Arami
While the majority of schools are very supportive of vaccination—I would say that most head teachers recognise that a well-vaccinated school community is going to have less absence, and that will contribute towards attainment, and that is what they are there to do, to provide education—I very much support what Will has said. There are occasions when head teachers have been criticised by parents for providing their data to the school-age vaccination teams—which is absolutely right and above board with regard to GDPR—and that has created for some a reticence and resistance to doing that, which means that the vaccination opportunities for those children are much reduced. The school-age immunisation teams, even if they might be coming in to provide flu in a particular session, will also review the vaccination status of each of the children, if they have the names in advance, and offer to the parents anything else that is missing for the child. When it works well, it is great. One thing I have been very cognisant of during this whole episode is that for the majority of people our standard offer within primary care and schools works well but that there is a significant proportion of the population for whom that does not work, for all the reasons that we are talking about here today. This is the bit that we really need to get in order to achieve nationally high vaccination status—how do we flex our system to enable it to provide a service outside of the standard at the moment? That is the million-dollar question that we all have.
The Chair
At the beginning when you all talked about your very mobile communities in your areas and so many people not being registered with a GP, with the vaccination system so heavily focused on service from GPs, I thought: how on earth do you reach those people? Will, you particularly talked about that. Is there anything else that can be done? Is it through the communities? Or is it by widening the places where people can get vaccinations, as you mentioned earlier? Or is it both?
Will Huxter
It is both. James mentioned community pharmacies. That is another point of access for people to use. Obviously this is a different population, but in London more Covid vaccinations were delivered in community pharmacies than outside of community pharmacies. They became a very popular and easily accessible way, without having to make appointments. There is a perception, which is not always true, that it is very hard to get an appointment with your GP to get vaccination. If that is the perception and sometimes the reality, there may be a particular time that you are ready to do it that does not work. But going back to my point about flexibility and joined-up data, I would like the position to be that every hospital that provides services to children has access to their child health record and can see whether they have been vaccinated, so that when they come for their out-patient appointment the hospital can say, “You’re not up to date for your MMR. We could do that for you now”. There are things such as that, where we have to take people where they are rather than assuming that they will make a particular effort to go for something else.
The Chair
That is very much emerging during the evidence that we are hearing. But the problem, as you have just highlighted, is joining up the data so that the patient’s record is complete wherever they have their vaccination.
Baroness Neuberger
And changing the way that we operate, because we operate in a way that is convenient for the service, not the punters.
Baroness Browning
You have had a lot of structural change in the way that vaccines are delivered in the past, and the committee is aware that you have yet more changes to come and that you are in the middle of them now with changes to the ICBs and so on. In the evidence that we have taken so far, we have struggled at times to understand the structure of accountability. Can I start by asking you, Will, who is responsible and accountable in your whole-of-London region for improving childhood vaccination coverage and reducing disparities? When you have identified that person, body or job title, how effective is leadership and co-ordination?
Will Huxter
As things stand, the statutory responsibility for that is with the regional office of NHS England. I am the Regional Director of Commissioning and it sits in my portfolio. We have a Regional Director of Public Health and regional director overall, but it sits within my responsibility. It is then discharged by the organisations that we commission services from. Dudu and I were both at a meeting last week of the immunisations board that is across London, which has ICB colleagues, local authority colleagues, UKHSA and others, because part of the importance of our role is to make sure that the structural change does not affect what is delivered and we try to make sure that we are working to a common strategy for what we want to do. As responsibilities get passed on, that will change. It is shared leadership, but the ultimate accountability sits with us. Certainly, we do not have the levels of uptake that I would like to see, and that is a constant focus of what we want to do. We talked about this last week but, again, we need to reorientate from thinking about people who find it easy to come through—as per James’s point about counting numbers—and think: how do we reach people who have never had any vaccination and no child in their household has ever had a vaccination? How do we tackle that? Other members of the population will come forward regardless. We try to need more root and branch on the equity side of things.
Baroness Browning
From what you see coming down the track—I know that it is not yet exact as to what the changes to the ICBs will be—how much flexibility will you have to put into practice those ideas when they are disagreed or decided?
Will Huxter
There are two aspects to that. There is strategic agreement that that is what we want to do. ICB chief executives and their teams, local authority colleagues and we have agreed on that. In the future, the team that I currently have working on immunisations in NHS England will become a team working on behalf of the ICBs in London. From the point of view of subject matter expertise, contact with communities and understanding of arrangements, that should be relatively smooth. I would not, of course, dispute that reorganisation always causes some disruption, but the programmes are good schemes that work well. What we need to make sure we are still doing is focusing on those communities that we are at the moment not reaching as well as we should do.
Baroness Browning
I will put it this way: will the buck still stop with you?
Will Huxter
No. The buck will stop with the ICBs. From the time of the legislation passing, it will formally become the responsibility of the ICBs. The regional office will hold the ICBs to account for what they do but the buck will stop with the ICBs.
Baroness Browning
I see, thank you. James, in relation to Hampshire and the Isle of Wight moving forward and this change to the ICBs and the wider NHS reforms, I do not know whether this is correct or not but there are question marks about existing ICBs being amalgamated. They may well get bigger, in the same way that we are going to see bigger police forces. What if your area, Hampshire and the Isle of Wight, which I know very well as I live on the Dorset coast and look out at the Isle of Wight, was joined together with Dorset and became one Dorset and Hampshire ICB? What sort of challenges would that pose?
James Roach
You are right to note the reorganisation. We will stand alone as an ICB moving forward. There are no planned mergers. In the instances that we have seen in other parts of our region where ICBs have merged, you are seeing more scale and easier alignment of that regional approach. But the risk, as always, is: can you get the balance right on the push at regional level and what you need to do locally on the pull? My experience in Hampshire is that we work really well with the NHS England public health immunisations and vaccinations team. We work together on local strategy. Similarly to London but on a smaller scale, we have a single point of co-ordination that will include those teams—the ICB and local authorities as well. It is really important to have that local authority/public health interface at place level. Where it is working well is that we are able to bring that commissioning expertise together. I talked about push and pull earlier—we almost have the push in the national policy, framework and strategy. The benefit of aligning it with local commissioners is that you can start to pull through solutions at a local level. Having that commissioning expertise in the conversation enables you to think about pathways and to think differently about how you can increase access and bring some of the services that were traditionally seen as national and regional into that local space.
Baroness Browning
It would give you a clearer view, would it not, if you had more local overview? Does that apply to Enfield as well?
Dudu Sher-Arami
While directors of public health do not have commissioning responsibilities, they have a statutory duty for assurance of things such as immunisation uptake and screening uptake. What that means in practice is probably slightly different in each area, but certainly it is about the role of public health in facilitating system-wide improvement and development of the system, and being able to use some of the public health expertise in understanding communities and their needs to feed into the commissioning and the provision of immunisation services. There may be something to consider about how that is strengthened, and how the role of director of public health is strengthened, in the relationship with the ICB. More often than not, directors of public health are a single appointment with the local authority rather than a dual appointment with the ICB as well, but there may be something to consider about strengthening the assurance role.
Baroness Browning
In practice, is there much competition between delivering the screening services as far as resources are concerned and vaccination services, as they seem to be in the same circle? When there is a government initiative, for good reasons—for some new screening, or for a new age block for screening—is it vaccination that very often loses out, or am I getting that wrong?
Dudu Sher-Arami
No, I do not think so. There are many similarities when we look at our intelligence about low vaccine uptake and low cancer screening uptake. There is a divergence there. I could have said everything that I said at the start about local deprivation and uptake about screening as well. There are many similarities. We have talked about how to further develop and sustain our engagement work, and something like that would also benefit other health issues and preventative health issues like screening as well.
The Chair
I fear that we have less than 15 minutes left but we have four questions to ask. We can perhaps go on till about 3.20 pm and give about five minutes to each question, so we are going to have to be very disciplined.
Lord Dholakia
I want to ask about the influence of the healthcare system on childhood vaccination coverage. I have two particular issues in mind. One is the funding arrangements, and the second one is data systems. You must have different systems in Enfield and Hampshire. How could you use the influence of funding arrangements to be used to help to improve coverage and reduce disparities in those areas? Secondly, what are the barriers to data collection and how could they be improved?
Dudu Sher-Arami
There are lots of opportunities to look at how the whole spectrum of the health service or indeed the public sector service supports vaccination and immunisation uptake. Will spoke earlier about the situation of a child coming into an out-patient clinic. There are lots of children, and that is a routine opportunity to check that child’s immunisation status and offering vaccination if they are missing anything, but we do not maximise those opportunities throughout the system. There are some good reasons why that does not happen—everyone is very busy and there are real constraints in time—but there are also potentially issues around people’s confidence in addressing those sometimes difficult vaccine-related questions. It is important to think about how we ensure that there is robust training for all healthcare service staff who have contact with children and families.
The Chair
Do you think that would save money?
Dudu Sher-Arami
It could possibly increase our vaccination uptake, which would prevent outbreaks. While I have not been able to do a cost analysis of what the outbreak in Enfield has looked like, if I had a hat then I would eat it if that was not the most expensive way of doing things.
James Roach
On funding mechanisms, you will remember that GPs and pharmacists broadly are independent businesses and contractors, so fiscally it needs to make sense. We often commission on a unit price. There are examples of where we try to incentivise GPs or healthcare professionals to act more proactively in deprived areas. This year in the GP contract we have a quality and outcomes framework, where there appears to be more incentive and more investment in vaccinating hard-to-reach communities. Another key issue with the money is not just what you get this year; it is about making sure that you get the same amount of money year on year so you can plan your business. Lastly, we hear a lot that it is not just about the delivery of the vaccine; there needs to be enough headroom for training, follow-up and connection into other healthcare services. So we have a really good foundation in funding, but we need to be a lot more flexible in how those funds can be used, how we incentivise long-standing problems and how we bring other contractors into the mix.
Will Huxter
We make our current systems quite complicated. As James has said, we have over 1,000 GP practices in London, and each of them is having to do the stuff around claiming the money for the system under which we pay for immunisations. We need to get to a better state where we commission a range of services for which there is a sum of money, and there is a focus on, as James is highlighting, higher levels of uptake among the more deprived communities. Without that, we are not going to have the population health gain that we need. Another thing I will say about costs is that the only thing more expensive than an outbreak is children getting unwell and being hospitalised as a result of not having been immunised. That has a broader impact on education as well as the time spent, sadly, in hospital for some individuals.
The Chair
It is very difficult to cost all that, is it not?
Baroness Freeman of Steventon
Each of you has mentioned the importance of data systems and the difficulties of them talking to each other and being useful. What are the main barriers for the development and deployment of more effective data systems, and how could we overcome them?
Will Huxter
One of the main challenges is that there are lots of different systems, so there is terrible interoperability. The ability of different systems to talk to one another, as Dudu mentioned earlier, is really problematic. Whenever we do bits of work looking in detail at particular populations, we find inaccuracies, whether that is a slight misspelling of a name or the fact that a child may have had some vaccinations abroad. There is a range of things that play into that. I have been really clear about the information that is required: from a technical point of view, it is just about making sure that all our systems are able to flow between one another. There is a consent issue as much as a technical issue with that about the perception of who owns the data, but it is the patient’s data and there should be the right for that to flow around the system. Certainly, in my experience of talking to patients, they often assume that everything is joined up already and are a bit surprised that their secondary care consultant cannot see the information their GP has, or vice versa. There is almost a cultural philosophical piece, and then there is making sure that immunisations, not just things like out-patient appointments, are visible across the comprehensive record.
Dudu Sher-Arami
It would be useful to consider a single vaccination record for each child. We have spoken a lot about flexibility in how payments happen. Primary care is paid to provide vaccinations but, in those communities where lots of people have their vaccinations abroad, the primary care professionals are not paid to update the vaccination record with a complicated vaccine history of their patients, sometimes requiring translation, for vaccinations that they have had abroad. If we do not account for the vaccinations that occur then we cannot understand what our population’s immunity level is, which is so important from a public health perspective.
James Roach
We have to link that to payment mechanisms as well. There has to be a correlation between what goes in and then how people are remunerated, to drive accuracy. My final point is about the NHS app. I am conscious that not everyone uses it, but even if we can get to 70:30 or 80:20 then that is a step in the right direction, with patients contributing their own data so that we can get accuracy.
The Chair
And indeed a digital red book, at long last, would be good too.
Dudu Sher-Arami
Can I add something?
The Chair
It will have to be very quick.
Dudu Sher-Arami
One sentence. We know that each vaccination within an area of higher deprivation needs a much greater degree of effort to be put in, and that needs to be very well reflected within our payment systems.
The Chair
Something has already been said about the training of the healthcare workforce, but Lord Randall is going to give you all an opportunity to say more about that.
Lord Randall of Uxbridge
Obviously healthcare professionals have an important role. I am wondering how much training they have and whether there is an opportunity for more public-facing workers generally to have that. How do we make sure they are giving out the right message?
Will Huxter
It is clear what the right messages are. There is good evidence about the efficacy and effectiveness of vaccination, but we do not always recognise the extent that staff are juggling a whole number of different things or what the particular focus is of their interaction with a patient at a particular time. We introduced a new vaccination programme, RSV, for respiratory illness in newborns, pregnant mothers and the elderly. The uptake of that has been really positive, and lot of that is about the trusted professional who you are having the interaction with. That is a range of people, whether it is health visitors, midwives or others who interact at different points. We likewise have really good uptake for antenatal and newborn screening programmes, which again is a point of particular trust. So it is predominantly about trust in the healthcare or other professionals who patients are interacting with. I am less worried about the information being available. Sometimes it is about how you give the message and how you can tell whether the person in front of you is ready to hear that message, as well as using faith and other community leaders to work with us on particular things. So there is a background context.
Baroness Hodgson of Abinger
Have you done any qualitative and quantitative studies on people who have not taken vaccinations and things? Have you dug into reasons why they have not?
Will Huxter
We have the quantitative data. In terms of qualitative, there has been a range of surveys. The UKHSA does a survey on attitudes to vaccination and we get a range of answers, access being one of them, but another is scepticism about the need for and effectiveness of vaccines in the context of some messaging, which is that vaccines can be harmful or that they do not have the desired impact. So there are a lot of different factors that people take into account, but access is probably highlighted more often than downright scepticism about the value of vaccination.
James Roach
To add to Will’s point, we try to offer an extensive programme free of charge to all staff working in health and social care so that we can start to make it a bit more everyone’s business and get people equipped at every point of contact. As you know, these healthcare professionals are time-pressed and under pressure, so you have to demonstrate the benefit of training. We should promote it as a key part of someone’s continuing professional development, a key part of how we want to develop services. Digital training is a lot more effective because people can deliver that in line with their professional obligations, so we need to be flexible in how we offer training. We should focus not only on the clinical parts of that team but on the non-clinical too. Social prescribing in primary care is a key issue. How do we equip our connectors and community contacts to better identify outreach groups and get messages out as well? There has to be a balance around administration, but training people to get out there, communicate and engage is just as important.
Dudu Sher-Arami
There are also opportunities to look at the rest of the public sector in terms of vaccination. Obviously clinical conversations need to happen in healthcare settings, but family hubs, schools and early years settings all provide opportunities to engage with families about health issues, including vaccination. The Government’s Best Start in Life programmes and focus on readiness for school fit very well into that sort of frame of work.
The Chair
That is a point very well made.
Baroness Andrews
This is a tough question because you have covered so many different aspects, both very good and a bit worrying, but can you each choose one thing that you think is imperative that we as a committee recommend in our report?
Will Huxter
There are a lot of things to pick from. The way in which we think about the population we are trying to reach needs to change. Baroness Neuberger made the point earlier on about trying to take longer-term views on things and lots of change. A focus on neighbourhood health is an absolute priority in the 10-year plan for what is happening within the NHS. We need to think about the health needs of the population in the round. Making sure that there is partnership between secondary care, primary care, the voluntary, community and faith sector and the local population is the way in which we need to deliver more and more stuff that is relevant to, and well accessed by, our population. Isolating immunisation separate from the rest of health is not helpful. It needs to be in the round of what is being provided to that population.
Baroness Andrews
We need to make sure that our structures reflect that.
James Roach
I support that. To lift a bit from Will’s proposal—this may be easy to suggest but it is not clear that it is the case—does this need to be more of a pan-government endeavour? Health, economy, science, communities and employment are all factors that have worked well previously. I wonder whether we need a clearer pan-governmental department statement and partnership-working approach in relation to the delivery of vaccines. That would ensure that the neighbourhood health approach that Will is promoting had a much clearer steer locally than pushing this agenda. It is not just about health; it is about all those agencies working differently in partnership.
Baroness Andrews
Bigger message, louder voice.
Dudu Sher-Arami
Mine is probably resourcing to enable more focused work in areas of higher deprivation, which is more costly; resourcing for training and making sure that it covers the healthcare workforce who are the vaccinators, as well as the workforce in other public sector organisations as well; and resourcing for engagement because, while there is no silver bullet of an answer to this question and engagement is certainly not a silver bullet, it is very important for those communities that are furthest from our system.
The Chair
I thank all three of you for your patience with us and all our questions this afternoon. We have learned a great deal from you. With that, I am going to close this evidence session.