Consultation outcome

Making vaccination a condition of deployment in the health and wider social care sector

Updated 10 December 2021

Applies to England

Aim of consultation

The aim of this consultation is to seek views on whether or not the government should extend the existing statutory requirement for those working or volunteering in a care home to be vaccinated against coronavirus (COVID-19) to other health and care settings, as a condition of deployment, and in addition, whether to introduce a statutory requirement to be vaccinated against the flu as a condition of deployment, as a means to protect vulnerable people.    

The government’s starting point in terms of who would be in scope is the Green Book, Chapter 14a - COVID-19 - SARS-CoV-2, and Chapter 19: Influenza which sets out clear advice that vaccination should be provided to healthcare and social care workers to:

• protect them and to reduce transmission within health and social care premises
• contribute to the protection of individuals who may have a suboptimal response to their own immunisations
• avoid disruption to services that provide their care.

Such a requirement, if introduced, would be implemented through a change to Regulations to ensure all those that are deployed to undertake direct treatment or personal care as part of a Care Quality Commission (CQC) regulated activity are vaccinated.

Despite COVID-19 and flu vaccines undergoing stringent safety assurances before they are authorised, it is clear that vaccine hesitancy exists as a real concern for some and is more prevalent within certain groups of our society. As such, there is a risk that some health and social care workers may continue to decide not to be vaccinated and therefore no longer meet the requirements to be deployed. A reduction in the number of health and social care workers, could, in turn, put additional pressures on the social and healthcare sectors. The alternative option to statutory changes would be to continue to rely on non-statutory measures to encourage vaccine uptake as outlined in Annex A below.

Background context

During the course of the pandemic the overriding concern for government, the National Health Service (NHS) and the care sector has been to protect the workforce, patients, and the users of services. Whether in care homes, at home, in hospitals or in general practice, everyone working in health and social care with vulnerable people would accept a first responsibility to avoid preventable harm to the people whom they are there to care for.

Prior to the pandemic, the voluntary approach to flu vaccination saw national vaccination rates in the health service increase from 14% in 2002 to 76% last year and in social care, to approximately 33% in care homes. However, those national figures masked much poorer uptake in some settings, with rates as low as 53% in some hospitals. For patients, care home residents and their families and friends, there was, and remains, uncertainty on whether they were afforded the added protection of vaccinated staff.  

While this was accepted by some in the past as the way of things, the impact of the COVID-19 pandemic in both hospitals and care homes raises the questions as to whether this should continue to be accepted as the norm.

Prior to the pandemic, workplace health and safety and occupational health policies were already in place which required the Hepatitis B vaccine for those deployed to undertake exposure prone procedures.

During the pandemic, following the development of COVID-19 vaccines, there has been a substantial and sustained effort to enable access to vaccines. This has resulted in high COVID-19 vaccine uptake in the population, including across health and social care staff. However, there is still variation within health and care settings - for NHS trusts, uptake rates can vary from around 83% to 97% for first dose (78% to 94% for both doses). In social care, 81% of domiciliary care staff and 75% of staff in other settings had received 1 dose of the vaccine (as of 19 August). See ‘Vaccine Uptake’ section below for further data.

To further increase uptake levels, regulations have already come into force which will mean that from 11 November 2021, all those working or volunteering in a care home will need to prove either their COVID-19 vaccination status or an exemption from having the vaccine. A number of social care stakeholders have called for parity in approach across the health and social care sectors, so that the most vulnerable are protected in every setting. 

The government is not alone in looking carefully at this issue with other European countries, as well as the United States, also considering or implementing mandatory vaccines for specific workers. For example, the French government has announced that COVID-19 vaccination is to be made compulsory for health and care workers from September.

Clinical rationale

The Joint Committee on Vaccination and Immunisation (JCVI) has advised that winter 2021 to 2022 will be the first winter in the UK when SARS-CoV-2 is expected to co-circulate alongside other respiratory viruses, including the seasonal flu virus. As we return to pre-pandemic norms, seasonal flu and SARS-CoV-2 viruses have the potential to contribute substantially to the ‘winter pressures’ faced by the NHS, particularly if infection waves from both viruses coincide. Vaccination against both COVID-19 and flu is a critical step in protecting vulnerable people as well as the wider health and social care system against a tough winter this year, and in future years.

Department of Health and Social Care (DHSC) officials working with the UK Health Security Agency (UKHSA) and Public Health England (PHE) have considered whether there could be defined minimum vaccine uptake rates for COVID-19 and flu in order to protect patients and people who receive care comparable with the approach taken for care homes. That approach set a COVID-19 vaccine uptake rate of 80% in staff and 90% in residents and was a recommendation derived from a model based on parameters specific to care homes as closed settings. However, we consider that it would not be possible to take a similar approach in settings such as hospitals, GP or dental practices and people’s homes because there is significantly more movement in and out, as well as mixing within the setting. It is now known that in all settings vaccinated individuals can be both infected and infectious so iterative review of any uptake rates may be needed in the future.

Instead, there are 3 areas of risk that should be considered:

• risk of interaction (that is the numbers into and out of the setting, for example, a GP practice vs a more ‘closed setting’ such as a care home)
• risk of vulnerability of the individual
• risk from settings with high risk procedures (for example, dentistry procedures)

The Scientific Advisory Group for Emergencies (SAGE) Social Care Working Group has also previously advised there is a strong scientific case for parity of approaches with respect to vaccination offer and support between NHS inpatient settings and care homes, given the similarly close and overlapping networks between residents or patients and workers of all kinds in both.

COVID-19 vaccination

Analysis from PHE indicates that the COVID-19 vaccination programme has directly prevented between 23.8 and 24.4 million infections, over 82,100 hospitalisations, and between 102,500 and 109,500 deaths.

Studies linking community COVID-19 testing data, vaccination data and mortality data indicate that both the Pfizer-BioNTech and Oxford-AstraZeneca vaccines are around 70 to 85% effective at preventing death from COVID-19 (Alpha variant) after a single dose. ^{[footnote 1][footnote 2]} Vaccine effectiveness against mortality with 2 doses of the Pfizer-BioNTech vaccine is around 95 to 99% and with 2 doses of the Oxford-AstraZeneca vaccine around 75 to 99%.

Studies have now reported on vaccine effectiveness against infection of the COVID-19 Alpha variant in healthcare workers, care home residents and the general population. For the Pfizer-BioNTech vaccine, estimates of effectiveness against infection range from around 55 to 70%, for the Oxford-AstraZeneca vaccine from around 60 to 70%. ^{[footnote 3][footnote 4][footnote 5][footnote 6]} With 2 doses of either vaccine effectiveness against infection is estimated at around 65 to 90%. ^{[footnote 6][footnote 7]}

For the COVID-19 Delta variant, studies have reported only a modest difference in vaccine effectiveness against symptomatic disease and similar vaccine effectiveness against hospitalisation after both doses of either the Pfizer-BioNTech vaccine or Oxford-AstraZeneca vaccine. ^{[footnote 7][footnote 8]}

As described above, several studies have provided evidence that vaccines are effective at preventing infection. Uninfected individuals cannot transmit; therefore, the vaccines are also effective at preventing transmission.

Beyond preventing infection, there may also be the additional benefit of reduced transmission by those individuals who become infected despite vaccination because of reduced duration or level of viral shedding. A household transmission study in England found that household contacts of COVID-19 Alpha variant cases vaccinated with a single dose had approximately 35 to 50% reduced risk of becoming a confirmed case. ^{[footnote 9]}

Flu vaccination

Flu vaccination has been recommended in the UK since the late 1960s, with the aim of directly protecting those in clinical risk groups who are at a higher risk of flu associated morbidity and mortality. The average number of estimated deaths in England for the 5 seasons 2015 to 2020 was over 11,000 deaths annually. This ranged from almost 4,000 deaths in the 2018 to 2019 season to over 22,000 deaths in the 2017 to 2018 season.

Those in at risk groups are around 11 times more likely to die from flu than someone not in a risk group. Serological studies in healthcare professionals have shown that approximately 30 to 50% of flu infections can be asymptomatic. ^{[footnote 10]} Contracting COVID-19 or flu presents a significant risk to the health of vulnerable people.

People infected with both flu and COVID-19 are more than twice as likely to die as someone with COVID-19 alone, and nearly 6 times more likely to die than those with neither flu nor COVID-19. ^{[footnote 11]}

The effectiveness of flu vaccine depends upon the composition of the vaccine, the circulating strains, the type of vaccine and the age of the individual being vaccinated - typically it is around 30 to 70% effective in healthy adults.

As with the COVID-19 vaccine, if an infection is prevented, then transmission is also prevented.

Vaccine uptake

This section sets out information on vaccine uptake by health and social care workers. The variation in the levels of vaccination are important to understand in considering whether further action by the government may be necessary.

COVID-19 vaccine

Social care

More than 1.2 million social care workers in England have now taken up the vaccination. As of 19 August 2021, vaccination uptake amongst eligible staff in JCVI cohort 1 was 91%, although in London this figure drops to 89%. For JCVI cohort 2, 87% of staff in younger adult care homes, 81% of domiciliary care staff, and 75% staff in other settings had received 1 dose of the vaccine (as of 19 August). However, there is some variation at regional level, in London 86% of younger adult care homes staff, 73% of domiciliary care staff and 69% of staff in other settings have received 1 dose.

Healthcare

The percentage of NHS trust staff who have received at least 1 dose (overall) is around 92% nationally, with 88% of staff having received both doses. The percentage of staff receiving a first dose is above 90% in all regions, bar London, which is at 86%. All data as of 31 August 2021, covering vaccinations up to 29 August 2021.

There is variation in uptake levels across NHS organisations, with NHS data showing that between NHS trusts, uptake rates can vary from around 83% to 97% for first dose (78% to 94% for both doses). Uptake for first doses is above 90% in more than three-quarters of NHS trusts. All data as of 2 September 2021, covering vaccinations up to 31 August 2021.

Vaccination uptake amongst primary care workers stands at 87% first dose with considerably more disparity at regional level, ranging from 76% in the East of England to 94% in the South West. All data as of 10 August 20201, covering vaccinations up to 31July 2021.  

Flu vaccine

Healthcare

Health care worker flu vaccine uptake has increased from 14% in 2002 to 2003 season to 76.8% last year. There remain wide discrepancies across the country. In the 2020 to 2021 season:

• seasonal flu vaccine uptake in NHS trusts ranged from 53% to 100%, with a single Trust achieving 100% vaccine uptake

• 59.4% of NHS trusts (129 out of 217) achieved vaccine uptake rates of 75% or more

• seasonal flu vaccine uptake in GP practices and independent sector healthcare providers (aggregated by Sustainability and Transformation Partnerships (STPs)), ranged from 60.8% to 92.6%. A total of 76.2% (32 out of 42) STPs reported uptake of 75% or greater

• the highest seasonal flu vaccine uptake by staff group in England was achieved among qualified nurses in GP practices, with an uptake rate of 84.8%. The lowest uptake was 75% in support to clinical staff

Social care

According to the Capacity Tracker, flu vaccine uptake among social care workers in care homes was around 33% last year - 48% for those directly employed and 36% for those employed through an agency - significantly lower relative to the COVID-19 vaccine. These numbers are excluding those with “Unknown” or “Not Declared” flu immunisation status.

Annex A includes further details on the action taken to drive vaccine uptake in health and social across both the COVID-19 and flu programmes.

Views on the policy intention

The aim of this consultation is to seek views on whether or not the government should extend the existing statutory requirement for those working or volunteering in a care home to be vaccinated against COVID-19 to other health and care settings, as a condition of deployment, and in addition, whether to introduce a statutory requirement to be vaccinated against the flu as a condition of deployment, as a means to protect vulnerable people.    

SAGE has advised that vaccination is a tool in preventing the transmission of both flu and COVID-19 in settings where vulnerable people receive a form of care.

As previously stated, vaccination reduces the risk of infection, which in turn reduces the risk of transmission. The more staff who are vaccinated against flu and against COVID-19, the more likely it will be that vulnerable people in their care are protected; staff themselves will be protected and their colleagues will also be protected.

In addition, a higher level of vaccination uptake is likely to reduce sickness absence at the times when vulnerable people are most likely to need health and social care. As of 4 August 2021, the number of sickness absences (7 day average) was 72,696 in NHS trusts, of which around 18,000 staff were absent for COVID-19 related reasons including the need to self-isolate. This shows around 5.6% of staff were absent, which compares to an average of 4.1% before the pandemic (in August 2019). In the first COVID-19 wave in April 2020, staff absence rates reached a peak of over 12%.

Question

Which of the following best describes your preference about the COVID-19 and flu vaccination status of the people who provide your care, your family member’s care or your friend’s care?

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• I feel strongly that they should be vaccinated

• I would prefer that they are vaccinated

• I don’t mind either way

• I would prefer that they are not vaccinated

• I feel strongly that they should not be vaccinated

• I don’t know

Question

Which of the following best describes your preference with respect to COVID-19 vaccination and flu vaccination being compulsory for those deployed to provide your care, your family member’s care or friend’s?

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• I feel strongly that vaccination should be compulsory

• I would prefer vaccination to be compulsory

• I don’t mind either way

• I would prefer vaccination not to be compulsory

• I feel strongly that vaccination should not be compulsory

• I don’t know

Question

If you are not a current service user or patient, we still welcome your view as you may need health or social care services in the future.

Which of the following best describes your preference about the COVID-19 and flu vaccination status of the people who would be providing your care?

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• I feel strongly that they should be vaccinated

• I would prefer for them to be vaccinated

• I don’t mind either way

• I would prefer for them not to be vaccinated

• I feel strongly that they should not be vaccinated

• I don’t know

Question

Which of the following best describes your preference with respect to COVID-19 vaccination and flu vaccination being compulsory for those who would be providing your care?

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• I feel strongly that vaccination should be compulsory

• I would prefer vaccination to be compulsory

• I don’t mind either way

• I would prefer vaccination not to be compulsory

• I feel strongly that vaccination should not be compulsory

• I don’t know

Question

Do you provide health care and/or social care to patients or service users?

• yes

• no

• I don’t know

Question

This question is for those who provide health care and/or social care to patients or service users

Which of the following best describes your preference about the COVID-19 and flu vaccination status of you and your colleagues who provide care to service users?

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• I feel strongly that we should be vaccinated

• I would prefer that we are vaccinated

• I don’t mind either way

• I would prefer that we are not vaccinated

• I feel strongly that we should not be vaccinated

• I don’t know

Question

This question is for those who provide health and/or social care to patients or service users

Which of the following best describes your preference with respect to COVID-19 vaccination and flu vaccination being compulsory for you and your colleagues who provide care to service users? 

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• I feel strongly that vaccination should be compulsory

• I would prefer vaccination to be compulsory

• I don’t mind either way

• I would prefer vaccination not to be compulsory

• I feel strongly that vaccination should not be compulsory

• I don’t know

Which persons should be required to be vaccinated?

An important part of consultation is that government makes clear how a statutory requirement for vaccinations as a condition of deployment could apply and to whom.

The government’s starting point in considering this would be the Green Book, Chapter 14a - COVID-19 - SARS-CoV-2, and Chapter 19: Influenza - health and social care staff who have frequent face-to-face contact with patients or clients and who are directly involved in patient or client care in either secondary or primary care or community settings.

Subject to consideration of the consultation responses, government’s approach in putting requirements on a statutory footing would be through an amendment to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In a similar way to the care home regulation (Health and Social Care Act 2008 (Regulated Activities)(Amendment) (Coronavirus) Regulations 2021), we would look to insert the requirement into the current 2014 Regulations which require that as part of providing safe care and treatment, providers must assess the risk of, and prevent, detect and control the spread of infections, including those that are healthcare associated (Part 3, fundamental standards, regulation 12).

Under this approach a requirement to be vaccinated would apply to all those that are deployed to undertake direct treatment or personal care as part of a CQC regulated activity. This would ensure that vaccination coverage protects vulnerable people and individual workers in health and social care settings including, but not limited to, hospitals, GP practices and also in a person’s home.

This requirement, if introduced, would apply to CQC regulated activities whether they are publicly or privately funded. The intention would also be for the requirement to apply equally where a regulated activity is delivered through, for example, agency staff, or contracted to another provider.  

CQC regulates the following activities:

• personal care

• accommodation for persons who require nursing or personal care

• accommodation for persons who require treatment for substance misuse

• treatment of disease, disorder or injury

• assessment or medical treatment for persons detained under the Mental Health Act 1983

• surgical procedures

• diagnostic and screening procedures

• management of supply of blood and blood-derived products

• transport services, triage and medical advice provided remotely

• maternity and midwifery services

• termination of pregnancies

• services in slimming clinics

• nursing care

• family planning services

We would welcome your views on whether anyone deployed to undertake direct treatment or personal care as part of a CQC regulated activity should be excluded. An activity that would be out of scope would be where in-person contact with a vulnerable person is absent, for example, triage and medical advice provided remotely.

This approach would cover those that are undertaking direct treatment or personal care. We are also considering whether some CQC regulated activities provided from residential or inpatient settings (for example, residential recovery services for drugs and alcohol, hospices, and registered extra care and supported living services) should be subject to this requirement. The case for this would be that they are sufficiently similar in nature to care homes. We have already introduced a condition of deployment in care homes to require people working or volunteering there to be vaccinated. Therefore, we welcome your views on whether any specific settings should follow the same approach.

We also want to carefully consider the role of ‘essential care givers’ – those friends or family who have agreed with the registered person, that they will visit regularly and provide personal care. Our intention is to follow the policy set out in the previous consultation response on making vaccination a condition of deployment in care homes and therefore not extend this policy to essential care givers.

We do not intend to extend this policy to friends and family members who visit people in health and social care settings or a person’s home. We strongly encourage friends and family members who are visiting health and social care settings and who are eligible to access both the COVID-19 and flu vaccinations as soon as they are able however, as long as visitors carefully follow the advice including on infection prevention and control (IPC) in a particular setting, we do not propose to extend the requirement to family visitors.

In addition, we would welcome your views on whether there are other professionals or volunteers deployed, but not undertaking direct treatment or personal care, that should also be included in the scope of the proposed policy. These individuals would work for a regulated service but do not provide personal care or treatment as part of the specific care of an individual. This could include a wide variety of staff such as those that prepare and serve meals, those moving patients or clients on trolleys or wheelchairs (porters), or reception and administration staff.

Question

Which of the following best describes your opinion of the requirement: Those deployed to undertake direct treatment or personal care as part of a CQC regulated activity in a healthcare or social care setting (including in someone’s home) must have a COVID-19 and flu vaccination?

Please provide a separate response for COVID-19 vaccination and flu vaccination. You may also provide a separate response for healthcare settings and social care settings.

• supportive

• slightly supportive

• neither supportive nor unsupportive

• slightly unsupportive

• not supportive

• I don’t know

Please provide details to support your answer.

Question

Do you think there are people deployed in or visiting a healthcare or social care setting (including someone’s home) who do not undertake direct treatment or personal care as part of a CQC regulated activity but should also be included within the scope of a requirement to have a COVID-19 and flu vaccine?

• yes

• no

• I don’t know

Question

Which people do you think should be covered by the scope of the requirement to have a COVID-19 vaccination and flu vaccination? (tick all that apply)

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• porters

• administration staff

• cleaners

• volunteers

• other (please specify)

• I don’t know

Question

For COVID-19 and flu vaccination are there people deployed to undertake direct treatment or personal care as part of a CQC regulated activity that should not be in scope of the policy?

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• yes

• no

• I don’t know

Please explain your answer

Question

Are there any other health and social care settings where an approach similar to adult care homes should be taken (that is, all those working or volunteering in the care home must have a COVID-19 vaccination or have an exemption)?

• yes

• no

• no opinion

Question

If yes, please select setting listed below. If other, please specify.

• hospice

• residential recovery services for drugs and alcohol

• registered extra care and supported living services

• registered Shared Lives services

• other

Under 18s

In the first phase of the COVID-19 vaccination programme, under 16 year olds were not eligible for vaccination and those aged 16 to 17 were only eligible for vaccination if they met the criteria for Phase 1 of the adult programme (if they themselves were at higher risk of serious outcomes from COVID-19 or in roles which increase the risk of transmission to vulnerable people, for example, those working in the health or social care sectors and carers (paid or unpaid)). Those 16 to 17 year olds who met the Phase 1 criteria were offered the full adult 2 dose vaccination course. Risk of serious outcomes from COVID-19 is strongly age related and for most under 18s the risk of serious outcomes is very small. As data on vaccine use in the under 18s was still at a very early stage in February this year, JCVI did not advise vaccination of healthy under 18 year olds during Phase 2 of the programme.

Since then, more evidence has emerged on both the benefits and risks for 16 to 17 year olds. Taking into account the rare risk of myocarditis or pericarditis as a side effect of Pfizer-BioNTech vaccine in younger age groups and particularly males, JCVI has issued advice to offer an initial dose to all remaining healthy 16 to 17 year olds. The effect of this will be reviewed and if JCVI are content they will recommend a second dose is given. With respect to flu, JCVI already advises vaccination for all those aged 2 to 15 or 50 and over and for at risk groups aged 16 to 49. 

The government will therefore look carefully at whether or not those aged 16 and 17 who are deployed to undertake direct treatment or personal care as part of a CQC regulated activity, should be included in the requirement to be vaccinated against COVID-19 and flu. This includes considering whether to amend the care home regulations, which currently exempt those under the age of 18, to ensure a single, consistent approach across the health and social care sector. The government will decide on which age groups are eligible for COVID-19 vaccination based on advice from JCVI.

Question

Which of the following best describes your opinion of the requirement: Those under the age of 18, undertaking direct treatment or personal care as part of a CQC regulated activity (in a healthcare or social care setting, including in someone’s home), must have a COVID-19 and flu vaccination?

Please provide a separate response for COVID-19 vaccination and flu vaccination. You may also provide a separate response for healthcare settings and social care settings.

• supportive

• slightly supportive

• neither supportive nor unsupportive

• slightly unsupportive

• not supportive

• I don’t know

Please provide details to support your answer.

Exemptions

For some people the clinical advice is that the COVID-19 and/or flu vaccination is not suitable for them. Therefore any statutory requirement would include exemptions on medical grounds which would be in line with the Green Book on Immunisation against infectious disease (COVID-19: the green book, chapter 14a; Influenza: the green book, chapter 19) and the JCVI which reflect clinical advice. Individuals would be exempt from the requirement if they have an allergy or condition that the Green Book lists (COVID-19: Chapter 14a, page 16; Influenza Chapter 19, page 17) as a reason not to administer a vaccine, for example, prior allergic reaction to a component of the vaccine. Some individuals may have an allergy or condition where the Green Book or JCVI advises seeking a professional medical opinion on whether they should be exempt.

Both nationally and internationally, no concerning safety signals have been identified so far in relation to the COVID-19 vaccination of women who are pregnant. JCVI updated their advice on 19 April, which now indicates that women who are pregnant should be offered vaccination at the same time as non-pregnant women, based on their age and clinical risk group, with Pfizer and Moderna vaccines as the preferred vaccines.

For flu vaccination, the Green Book (Influenza Chapter 19, page 17) states that the flu vaccine should be offered to pregnant women as the risk of serious illness from flu is higher in pregnant women. In addition, a number of studies show that flu vaccination during pregnancy provides passive immunity against flu to infants in the first few months of life following birth. ^{[footnote 12][footnote 13][footnote 14][footnote 15]}

The government would consider the least burdensome way for people to demonstrate that they are medically exempt from the COVID-19 and/or flu vaccination building on the approach already being implemented in relation to care homes. Questions on this subject are included in a later section: ‘Considerations relating to implementation’.

The policy would be reviewed if significant obstacles would prevent eligible workers from accessing the flu and/or COVID-19 vaccination in a timely and accessible way for example, due to vaccine supply issues or changes in national clinical guidance.

Question

Do you agree or disagree that exemption from COVID-19 vaccination and flu vaccination should only be based on medical grounds?

Please provide a separate response for COVID-19 vaccination and flu vaccination.

• strongly agree

• somewhat agree

• neither agree nor disagree

• somewhat disagree

• strongly disagree

• I don’t know

Question

On what other basis, if any, should a person be exempt from this requirement?

Consideration of potential impacts

Equality impacts

Our initial Public Sector Equality Duty (PSED) analysis indicates that making COVID-19 and flu vaccinations a condition of work in health and social care could impact certain groups. Analysis is based on NHS workforce and General Practice workforce data published by NHS Digital. ^{[footnote 16]} While the workforce data available represents most (but not all) of the impacted staff groups, there is no evidence to suggest that the composition of the workforce referenced below, differs significantly to the composition of the complete list of impacted staff groups. Further detail and consideration of impacts for those with protected characteristics is set out at Annex C.

We are keen to ensure that no group is differentially impacted by this new policy should it be implemented. Our aim is to help protect those working and being cared for and supported in health and social care settings, from the potential harmful outcomes of COVID-19 and flu infection.

Vaccination becoming a condition of deployment would be likely to have a particular beneficial effect on the outcomes of COVID-19 or flu infection in some staff groups where vaccine uptake is lower as a result of protection against infection that they might not otherwise have had.

Wider Impact

In addition, to a Public Sector Equality Assessment, we also want to carefully consider the regulatory impacts of any legislative change. This would consider the wider costs and benefits of the policy as well as costs to businesses. 

It is recognised that some members of staff may choose not to be vaccinated, even if the vaccination is clinically appropriate for them. In these circumstances, policy implementation may result in them no longer being able to work in a health and social care setting or the member of staff choosing to leave. We are asking a question in this consultation about the possible impact on staffing levels, if, however so arising, members of staff leave the health and social care workforce rather than be vaccinated. This may be a particular issue in some local areas where uptake is lower or where recruitment is more difficult. 

During the consultation period, we intend to discuss directly with employers the anticipated impact on individuals and the employment law consequences. Providers will be supported to manage this in a way which does not destabilise the provision of safe, high quality care. If the policy is implemented, operational guidance for providers would be published to set out the implications of the policy for managers and members of staff.

Alternative approach to increase uptake

As set out earlier, an alternative approach would be to continue to rely on non-statutory measures to encourage COVID-19 and flu vaccine uptake. A summary of the actions taken to increase uptake for both COVID-19 and flu vaccine is set out at Annex A.  

The benefit of this approach would be to avoid a risk of potential impacts on staffing levels and also allow people to retain personal choice about vaccination. However, the risk is that such an approach does not achieve the policy intention that all those deployed in providing direct care and treatment are vaccinated in order to protect the people in their care. 

We would welcome your views to the questions below in relation to the potential impacts in relation to equalities, other wider impacts, and what other non-statutory actions could be taken to further increase uptake in those providing care and treatment.

Question

Are there particular groups of people, such as those with protected characteristics, who would particularly benefit from COVID-19 vaccination and flu vaccination being a condition of deployment in healthcare and social care?

• yes

• no

• not sure

Question

Which particular groups might be positively impacted and why?

Question

Are there particular groups of people, such as those with protected characteristics, who would be particularly negatively affected by COVID-19 and flu vaccination being a condition of deployment in healthcare and social care?

• yes

• no

• not sure

Question

Which particular groups might be negatively impacted and why?

These questions are specific to those who manage frontline health and care workers.  

Question

Thinking about circumstances in which staff fall within a requirement to be vaccinated but remain unvaccinated, how do you anticipate you would respond?

• redeploy unvaccinated staff

• cease employment for unvaccinated staff

• other (please specify)

• not applicable

Question

Do you have concerns about the impact of a vaccination requirement policy on the ability of your organisation to deliver safe services?

• yes

• no

• I don’t know

Question

Which of the following are concerns that you have about the impact of a vaccination requirement policy on your organisation? (tick all that apply)

• some staff may refuse the vaccine and leave their current job

• some staff may leave in protest at the policy, if this conflicts with their personal beliefs

• remaining staff may resent the requirement, reducing morale

• staff may seek to challenge employers in court

• the supply of alternative trained staffing available

• the cost of short-term staff cover

• the cost of recruiting new permanent staff

• the time it will take to recruit new permanent staff

• time taken to train new members of staff

• other (please specify)

• I don’t know

Question

Please provide an estimate of the scale of potential impact

• severe impact

• major impact

• moderate impact

• minor impact

• insignificant impact

• I don’t know

Question

What, if anything, do you think could minimise any negative impact of a vaccination requirement policy on the healthcare and social care workforce? (tick all that apply)

• ease of access to vaccination

• access to up to date information

• support from local vaccination champions

• I don’t know

• none

• Other (please specify)

Question

Which of the following, if any, do you think your organisation could benefit from as a result of a vaccination requirement policy? (tick all that apply)

• reduction in patient or client morbidity or mortality

• prevention of outbreaks

• reduced levels of staff sickness absence

• reduced number of staff self-isolating after being in contact with someone testing positive for COVID-19

• cost savings from reduced bank or agency staff needed to cover staff sickness absence

• time saved by needing to acquire less staff to cover staff sickness absence

• reduction in staff anxiety about contracting COVID-19 and/or passing it on to friends or family

• reduction in the anxiety of family and friends of those being cared for

• none

• other (please specify)

• I don’t know

Question

Please provide an estimate of the scale of potential benefit

• very substantial benefit

• substantial benefit

• moderate benefit

• minor benefit

• insignificant benefit

• I don’t know

Question

Do you think a vaccination requirement policy could cause any conflict with other statutory requirements that healthcare or social care providers must meet?

• yes

• no

• I don’t know

• not applicable

Question

Please give further detail on other statutory requirements that a vaccination requirement policy could conflict with.

Question

Thinking about your staff who were initially hesitant to get vaccinated, what were the effective steps and actions that led to those staff accepting the vaccine?

Considerations relating to implementation

For the purposes of this section – the registered person in respect of a regulated activity is either the service provider or the registered manager, who is an individual appointed by the provider to manage the regulated activity on their behalf, where the provider is not going to be in day-to-day charge of the regulated activities themselves. As a registered person, the registered manager has legal responsibilities in relation to that position.  

Subject to consideration of the views gained as a result of this consultation, government’s approach in putting vaccination requirements on a statutory footing would be through an amendment to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Such an amendment would insert the requirement as a new provision in the fundamental standards in Part 3 of the Regulations, most likely into regulation 12 (which deals with safe care and treatment) as a supplement to regulation 12(2)(h), which requires that, as part of providing safe care and treatment, providers must assess the risk of, and prevent, detect and control the spread of, infections, including those that are healthcare associated. The Code of Practice on Infection Prevention and Control and its associated guidance would also be updated. This Code is issued by the Secretary of State under section 21 of the Health and Social Care Act 2008 and to which providers must have regard when complying with their obligations under regulation 12 of the Regulations. Draft amendments to the Code of Practice have been published alongside this consultation (see Annex B). We would welcome your views on this by answering the questions below.

Under this approach, it would be the responsibility of the CQC registered person (that is the service provider or registered manager) to check evidence that those deployed to undertake direct treatment or personal care as part of a CQC regulated activity are vaccinated, or medically exempt from vaccination. This means that workers would need to provide evidence to the registered person that they have been vaccinated.

The government is carefully considering the best way for people to prove that they have been vaccinated to the registered person. This may involve, for example, showing vaccination status on a mobile phone app or via a non-digital route (hard copy certificate). Lessons learnt from the implementation of the COVID-19 care home regulations will help inform the implementation in other health and social care settings.

The government is also considering what would be an appropriate grace period before the new regulations would come into force.

It is our expectation that the registered person would keep a record of vaccinations as part of their staff employment or occupational health records.

It is not our intention to make vaccination a condition of deployment in the unregulated sector. However, it is vital that high levels of vaccination are achieved among those working for these services, as a significant number of care recipients will have a heightened risk of severe outcomes following COVID-19 or flu infection. We therefore welcome your views on how the government could encourage vaccine uptake in the unregulated sector.

In the event government pursues this policy following consultation, we would work with our partners across the health and social care sector to develop operational guidance in order to facilitate implementation.

Boosters and mixed doses

The regulations relating to vaccination as a condition of deployment in care homes requires all those that are deployed in a care home to be vaccinated with a complete course of doses of COVID-19 vaccine as defined by MHRA licensing, unless exempt. At the time these regulations were made a complete course did not include a booster dose as JCVI had not provided advice on potential COVID-19 vaccine boosters at this point. JCVI interim advice on COVID-19 booster vaccines is that any potential booster programme should begin from September 2021 in order to maximise protection in those who are most vulnerable to serious COVID-19 ahead of the winter. Final JCVI advice on any booster programme is due shortly. Following this advice, the government will consider the incorporation of any booster dose, in addition to the primary dosing schedule, within the requirement of a complete course. 

The government will also consider whether to amend the care home regulations as necessary to ensure a single, consistent approach across the health and social care sector with respect to the number, and type, of vaccine required. Any final decision is subject to JCVI advice. 

The requirements in relation to care homes do not currently recognise people as vaccinated where they have had mixed doses of COVID-19 vaccine or where they have received a full course of a non-MHRA approved vaccine. The government will look carefully at whether or not mixed doses, and if so which forms of mixed doses, should be included in future requirements, including seeking relevant public health advice. The government will also look carefully at whether or not vaccines regulated or administered abroad, should be included in future requirements, including seeking relevant public health advice.

The role of the Care Quality Commission

Under the approach set out above it would be the CQC’s role to monitor and take enforcement action in appropriate cases. 

At time of registration and when inspected, the registered person would have to provide evidence that those deployed to undertake the regulated activity have been vaccinated with MHRA-approved COVID-19 and Flu vaccines.

In case of non-compliance with the legislation, CQC would take a risk-based and proportionate approach to enforcement, looking at all the evidence identified and whether the public interest test is met, in line with its enforcement policy. CQC has civil enforcement powers and in the most serious of cases, criminal enforcement against the provider or registered manager may be appropriate.

Civil enforcement options available to CQC include issuing:

• a warning notice
• a notice of proposal or decision to impose, vary or remove registration conditions
• a notice of proposal or decision to suspend or cancel registration
• an application to court for immediate cancellation of registration where there is serious risk to a person’s life, health or well-being
• an urgent notice of decision to suspend or vary conditions of registration where there is risk of harm to a person

Regulation 12 imposes a requirement on providers and registered managers to provide safe care and treatment. This includes a requirement for the provider and registered manager to assess the risk of, and prevent, detect and control “the spread of, infections, including those that are healthcare associated”. This is supplemented by the Secretary of State’s IPC Code issued under s.21 of the Health and Social Care Act 2008. Where a breach of regulation 12 results in avoidable harm or a significant risk of avoidable harm to a service user, the provider or registered manager may be guilty of a criminal offence, and the CQC will look at whether to take criminal enforcement action. The maximum fixed penalty notice is £2,000 or £4,000, in respect of an offence committed by a registered manager or provider respectively. It is a defence for a registered person to prove they took all reasonable steps and exercised all due diligence to prevent the breach of regulations.

Question

The question below is specific to those people delivering health and care services to patients and users of services.

How would you prefer to show that you have been vaccinated for both flu and COVID-19 or that you are exempt from vaccination?

• mobile phone app

• written self-declaration

• I don’t know

• other (please specify)

Question

This question is specific to those managing frontline healthcare and social care workers as we want to understand how managers would respond to staff that aren’t vaccinated. 

The people you deploy would need to be able to show that they had been vaccinated for both flu and COVID-19 or are exempt from vaccination. How would you prefer that they do this?

• mobile phone app

• written self-declaration

• I don’t know

• other (please specify)

Question

What could the government do to encourage those working in unregulated roles to have the COVID-19 and flu vaccine?

Question

We would welcome any comments you may have relating to Annex B - proposed addition to the code of practice – criterion 10

Question

We welcome any further comments you may have relating to this consultation.

Annex A

What the government has done to encourage COVID-19 vaccine uptake in health and social care

On 13 February 2021, we published the UK COVID-19 vaccines delivery plan, setting out the significant programme of work underway to drive vaccine uptake, including actions to improve access and to address the concerns of those who may be hesitant to receive the vaccine.

Social Care

We are delivering a targeted programme of work to support vaccine uptake among social care staff. In order to build confidence in the vaccine among the workforce, we have delivered an extensive communications programme which includes:

• bespoke communications materials (posters, videos, leaflets, and shareable social media assets) shared across a variety of channels

• a paid advertising campaign targeting social care workers with digital advertising to build vaccine confidence and encourage booking on the National Booking Service

• a stakeholder toolkit (Q&As, guidance and communications materials)

• positive messaging using influencers, leaders and care home workers who have already been vaccinated to boost confidence and tackle misinformation

• content in different languages and briefings with different faith groups who have expressed interest in co-creating vaccine content

• webinars for social care workers, including those where clinical experts answered social care workers’ questions and concerns about the vaccine

We continue to work closely with partners and stakeholders to identify and progress further actions at local, regional and national level to increase vaccine uptake among adult social care staff.

Healthcare

The NHS has adopted an engagement strategy centred around data, listening directly to the questions and concerns of the NHS workforce, and targeting communication in a supportive manner in order to ensure every member of the NHS workforce is able to make an informed decision regarding vaccine uptake. Specific steps taken to increase vaccine uptake include:

• using trusted messengers to deliver information and address concerns:

  • delivery of ‘virtual Town halls’ at providers using local clinical leaders, staff network leads, and chaplains to address concerns

  • engagement session and FAQs to the HR directors to dispel myths and support understanding of the vaccine rollout– over 100 HRDs attended, representing major Trusts across the country

  • Chief People Officer (CPO) Ethnic Minority Clinical Advisory group of leading researchers, trade unions, representative bodies amplified messages – with the membership working with their constituents to improve vaccine uptake

  • CPO Estates and Facilities reference group – representatives from major trusts and organisations representing over 185,000 estates and facilities staff

• CPO Pastoral, Faith and Spiritual Leaders group – represent more than 90% of faith in the NHS, representatives of organisation employing over 200,000 staff

  • Muslim and African Caribbean Insight Group - groups of over 30 influential religious, community, medical and academic leaders. These leaders between them have held over 100 webinars with a reach of over 100,000. The group included membership from the 3 largest Muslim TV networks, the largest representative body of Muslim healthcare workers and the largest Somali representative body in the country

  • 5 London wide staff QA session focuses on fertility and pregnancy. Videos produced dispelling myths from Chief Midwifery Officer and leading clinicians on vaccines and fertility

• supportive conversations:

  • CPO (NHS) wrote out to all Trust Chief Executives and human resources leads requesting them to ensure that all NHS staff had a supportive 1 to 1 conversation with a line manager (or person of trust) to address their specific concerns around vaccine uptake. This was based on learning from primary care which showed that an informative 1 to 1 conversation had the potential to reverse initial vaccine refusal by 70% of these conversation Following these conversations there was an increase in vaccine uptake across all regions with some regions increasing by more than 10%

• notable steps from trusts including those based in London include:

  • clearly visible ‘vaccine champions’ in each Trust – protecting time to act as visible vaccine advocates and be a point of contact for those who had concerns in their department

  • ensuring clinical insight is at the centre of delivery – a trusted medical voice is often critical to shifting staff from a position of hesitancy to confidence. Our learning from primary care shows that having a 1 to 1 conversation with a Clinician can turn hesitancy into acceptance in 70% of cases

  • buddying

  • well performing Trusts with less well performing Trusts to share best practice and learning around vaccination strategies

  • using Faith Leaders – Trusts continue to engage with their faith leaders in the vaccine roll out campaign. This was particularly successful during Ramadan, which presented a unique opportunity to use Trust Imams to help advocate for the vaccine by using our national Workplace Considerations for Ramadan

  • flexible timings of and access to vaccine hubs – vaccine hubs that cater for night staff and later opening hours. Messaging continues to staff to present their ID at alternative vaccine locations, such as pharmacies, to receive their vaccine at a convenient time and location

  • use of staff networks - Supporting organisation and engagement of BAME, Women’s and similar networks, and encouraging staff attendance

  • QA Virtual Events on Fertility – attended by members of staff across London, providing colleagues the opportunity to raise queries and concerns around the vaccine’s impact on fertility among male and female members of staff

What the government has done to encourage Flu vaccine uptake

Social care workers

To ensure all social care workers have access to the flu vaccine, the government each year has funded a complementary flu vaccine offer via the NHS to ensure all adult social care workers who are unable to access a vaccine through their place of work can access a free vaccine through their GP or pharmacy. For the 2020 to 2021 season the government provided a 100% offer to all adult social care workers irrespective of whether they had occupational health schemes. Other steps the government has taken to increase vaccine uptake include:

• removed barriers to vaccination, for example, ID requirements

• enabled pharmacists to vaccinate adult social care employees at their place of work, meaning that social care workers did not have to take time out of work or travel in order to get their vaccine

• produced bespoke communications materials (posters, videos, leaflets, and shareable social media assets) shared across the CARE App, weekly newsletter, and adult social care and DHSC social channels

• paid advertising campaign targeting social care workers with digital advertising to build vaccine confidence

• facilitating healthcare professionals (including registered nurses) to give flu vaccines to staff as part of an NHS or local authority occupational health scheme

Healthcare workers

Since 2011 there have been several interventions which, when tracked against uptake rates, have demonstrated a positive impact:

• in the 2011 to 2012 season as part of a programme to tackle low rates of vaccination, a ‘flu fighter’ campaign, delivered by NHS Employers, was funded by the Department of Health (now DHSC) to encourage higher levels of flu vaccination uptake in healthcare workers. In the 2019 to 2020 season responsibility passed to PHE and NHSEI to deliver the marketing campaign

• in the 2013 to 2014 season DHSC set a 75% ambition and the Commissioning for Quality and Innovation (CQUIN) scheme was mobilised

• in the 2018 to 2019 season ‘opt-out’ form had to be completed by staff

• in the 2019 to 2020 season – NHSEI introduced a ‘buddying’ system linking high and low performing trusts

• specific resources to engage with diverse audiences

• a letter from NHS England senior clinicians to trust CEOs to stress the importance of staff flu vaccinations and encourage staff uptake

• collection of case studies for healthcare worker vaccinations, shared best practice and key learnings from trusts with high uptake

• disseminated key campaign messages via bulletins, social media and stakeholder channels

In addition to these interventions, healthcare worker uptake was carefully monitored by NHS England and there were regular engagement meetings with regions to review progress within trusts and highlight areas of concern.

Annex B - proposed addition to the code of practice – criterion 10

Providers of regulated activities

Registered providers of regulated activities ^{[footnote 17]} should ensure they have policies and procedures in place with regard to COVID-19 and flu vaccination such that:

• those deployed to undertake direct treatment or personal care as part of the carrying on of a CQC regulated activity must provide evidence to the registered person, demonstrating that they have received the required doses of an MHRA approved COVID-19 vaccine and flu vaccine within the specified grace period, unless: those deployed can provide evidence that there are clinical reasons why they should not be vaccinated with any authorised COVID-19 and/or flu vaccine, in line with the Green Book on Immunisation against infectious diseases
• for those deployed who are unable to be vaccinated due to clinical reasons, registered managers (or the equivalent person) will have completed risk assessments and taken appropriate actions to mitigate risks

The registered provider will need to be able to demonstrate that:  

• there is a record to confirm that evidence stated above has been provided. This record will be kept securely by the registered manager (or equivalent person) in compliance with the Data Protection Act 2018  

• the eligibility for vaccination of those deployed is regularly reviewed in line with Regulation 12  

• there is appropriate support and education of those deployed in relation to the vaccine  

• those deployed are provided with the appropriate support to access vaccination

Annex C

Equality Impacts:

Our initial PSED analysis indicates that making COVID-19 and flu vaccinations a condition of work in health and social care could impact certain groups.

Healthcare workforce

Analysis is based on NHS workforce and General Practice workforce data published by NHS Digital. ^{[footnote 18]} While the workforce data available represents most (but not all) of the impacted staff groups, there is no evidence to suggest that the composition of the workforce referenced below, differs significantly to the composition of the complete list of impacted staff groups.  

Sex

Women make up over 75% and 80% of the NHSand General Practiceworkforce respectively. May to June 2021 data from the Office of National Statistics (ONS) showed that COVID-19 vaccine hesitancy is equal for men and women (at 4%) (although other evidence points towards vaccine refusal being lower in men). Women may face more barriers to accessing vaccines (for example, more caring responsibilities which may impact on their ability to travel to a vaccine centre). Consideration will be given to the most effective way of mitigating access issues should this policy be implemented.

Sexual orientation

Around 70% of the NHS workforce are heterosexual, 1% bisexual and 2% homosexual (18% of staff do not disclose their sexuality). These proportions generally stay consistent across individual staff groups (except amongst ambulance and ambulance support staff where homosexual and bisexual proportions are considerably higher). There is no data on the prevalence of vaccine hesitancy by sexual orientation. Given that individuals are not required to disclose their sexual orientation to healthcare professionals, it will be a challenge to determine the full impact of this policy for these groups, if implemented.

Gender reassignment

We do not have data on the number of transgender or gender non-conforming people in the healthcare workforce. There is also no evidence that this group experiences higher levels of vaccine hesitancy. However, there are reports that persons with this protected characteristic have faced some issues when accessing healthcare which can deter transgender people from accessing medical treatment. As a result, they may be less likely to be registered with a GP, or less likely to respond to communication inviting them to have the vaccine. The implementation of the government’s LGBT Action Plan is ensuring that issues such as access to healthcare and public health improve for this group. Policy implementation will ensure that vaccines are easy to access (for example, administered at workplaces). However, due to the lack of data available, it will be a challenge to determine the full impact of the policy on this group.

Disability

Disabled staff make up around 4% of the NHS workforce (although 10% do not disclose their disability status). Staff with disabilities who are clinically advised against vaccination would be exempt from this policy. This policy would however, have a positive impact on exempt staff with disabilities if a greater number of their colleagues were vaccinated and therefore provided them with additional protection. Some disabled staff may face access issues which may result in them being less likely to have had the vaccines prior to this policy being implemented, for example, lack of information in an accessible format or difficulty in travelling to vaccination centres. Consideration will be given to the most effective way of mitigating access issues, including ensuring that all guidance and information is readily available in a variety of formats.

Age

Within the NHS workforce, the proportion of those aged between 25 to 34, 35 to 44 and 45 to 54 is approximately 25% for each age bracket. Around 6% of staff are aged below 25, and 2% are aged 65 or over. Ambulance and support staff tend to have a higher representation of younger people, whereas older people are more represented in roles within NHS infrastructure support. If implemented, this policy is likely to have a beneficial impact on older staff, given that increased age is a risk factor for poorer outcomes of infection. Recent ONS data show that levels of COVID-19 vaccine hesitancy in the general population are higher in younger people – 9% in those 18 to 21 years, and 10% in those aged 22 to 25 compared with 4% in the general population. This may possibly be because they feel themselves to be at lower risk of death or adverse outcomes from infection. Whether or not this policy is implemented, to encourage uptake in younger people, the government will continue to highlight the potential benefits of vaccination to one’s colleagues, patients and families in addition to personal benefits.

Religion or belief

Christianity is the most widespread religious belief in the NHS Workforce (at 43%), followed by atheism (12%), with the majority of other beliefs also represented. Recent ONS data indicate that COVID-19 vaccine hesitancy was higher for adults identifying Muslim (15%) or ‘other’ (11%) as their religion, when compared with adults who identify as Christian (3%). There was no statistically significant difference when compared with any of the remaining religious groups. A number of people may be opposed to vaccination in principle due to their beliefs, either religious or nonreligious. If this policy is implemented, people who hold these beliefs may be likely to feel compelled to have a vaccine they do not want, or, by refusing to have the vaccinations, be unable to satisfy a statutory requirement which may ultimately result in them losing their job.

The government has taken, and will continue to take steps, to ensure religious groups are engaged. See Annex A on what government has done to increase uptake of flu and COVID-19 vaccines in different groups.

Pregnancy and maternity

As the healthcare workforce is predominantly female, the incidence of pregnancy and maternity among the workforce is higher than the general population. Pregnant persons are currently prioritised for seasonal flu vaccinations (see section on ‘exemptions’). As set out earlier in this consultation, in April 2021, JCVI updated their advice on vaccination during pregnancy to state that pregnant persons should be offered the COVID-19 vaccine at the same time as people of the same age or risk group. While vaccination is encouraged during breastfeeding, previously, routine vaccination during pregnancy was not advised. As a result, pregnant and breastfeeding healthcare staff may be less likely to have already been vaccinated against COVID-19. However in July 2021, the Chief Midwifery Officer for England urged pregnant women to get vaccinated and The Royal College of Midwives and Royal College of Obstetricians and Gynaecologists have also both recommended the COVID-19 vaccine as one of the best defences for pregnant women against severe infection.

Marriage and civil partnerships

Currently, we have no evidence to indicate that making COVID-19 and Flu vaccination, a condition of deployment will have a greater or lesser impact depending on marital or partnership status.

Race

Minority ethnic groups account for over 20% of the NHS workforce and over 15% for the General Practice workforce. There is evidence from previous vaccination programmes, that ethnic minority groups may be more hesitant about vaccinations more generally, for example, seasonal flu and pneumococcal vaccines. Although this trend was observed early in the pandemic, vaccine hesitancy has reduced (though is not evenly spread) across the population. More recent analysis by the Office for National Statistics (May to June 2021) indicate that Black or Black British adults had the highest rates vaccine hesitancy (18%) compared to White adults (4%). Other research shows that vaccine coverage - though high (72.9%) - was lower in people of Black, and higher in people of Asian ethnicity, when compared to White ethnicity (adjusted for age in line with the vaccine roll out). 

Factors influencing vaccine uptake predate COVID-19 and include issues such as lower trust and confidence in vaccine effectiveness and safety, access barriers and socio-economic status. The government has taken a multi-channel approach to encouraging vaccine uptake in ethnic minorities. See Annex A on what government has done to increase uptake of flu and COVID-19 vaccines in different groups. In addition to the aforementioned actions, initiatives have also included (but not limited to):

• working with specialist agencies to hold a series of roundtables for ethnic minority healthcare professionals, religious and community leaders to act as ambassadors within their communities
• the development of editorial content packages with trusted voices among ethnic minority healthcare professionals and celebrities, who feature in media opportunities and digital content

Current evidence suggests that individuals from minority ethnic groups are at increased risk of mortality from COVID-19. Persons of Black African and Black Caribbean descent appear to be at greatest increased risk. In England, it is likely that health inequalities known to affect minority ethnic groups, may be increasing the risk of transmission and the risk of mortality from COVID-19. Black, Asian and Minority Ethnic groups have been identified as less likely to get vaccinated. Therefore, making COVID-19 vaccination a condition of deployment is likely to have a particular beneficial effect on the outcomes of COVID-19 infection in some staff from these ethnic groups through access to protection against the virus through vaccination, that they might not otherwise have had.

As set out earlier in this consultation, healthcare workers are at higher risk of flu infection than the general population. Additionally, there is evidence to suggest that in persons not prioritised for flu vaccination (that is no long term medical conditions etc.), there are increased rates of flu among Black, South Asian and Mixed groups, when compared to the White British group. The associated increase in morbidity and absenteeism from increased rates of infection suggests that making flu vaccination a condition of deployment is likely to have a beneficial effect on the outcomes of flu infection in staff from ethnic minorities.

Social care workforce

Sex

There are many more women than men in the social care workforce. The adult social care workforce in the 2019 to 2020 season comprised 82% female and 18% male workers. As a result more women will be impacted than men by a policy requiring COVID-19 vaccination in care homes. Women may face more barriers to accessing vaccines (for example, more caring responsibilities which may impact on their ability to travel to a vaccine centre). Consideration will be given to the most effective way of mitigating access issues should this policy be implemented. The impact of a vaccine as a condition of deploying staff to work in the adult social care sector could lead to women being disproportionately at risk of facing disciplinary action at work and potentially losing their jobs.

Sexual orientation

There is no evidence available on the demographics of the adult social care workforce regarding sexual orientation. (See section on ‘Sexual Orientation’ for the healthcare workforce for wider considerations for this group).

Gender reassignment

We do not have data on the number of transgender or gender non-conforming people in the social care workforce. (See section on ‘Gender Reassignment’ for the healthcare workforce for wider consideration for this group).

Disability

According to Skills for Care reportbased on the Labour Force Survey (LFS), 18% of the population of England is disabled. LFS states that 22% of workers in social care occupations are disabled according to the Disability Discrimination Act 1995 (DDA) definition. But Skills for Care data (ASC-WDS) which are employer reported show 2% disability amongst workers as it only captures the LFS equivalent of ‘work-limiting disability’. Although we lack data on the proportion of staff whose disability prevents them from receiving the COVID-19 vaccine, this policy would have a positive impact on them if a greater number of their colleagues were vaccinated and therefore provided them with some protection.

Age

Skills for Care data suggest that the average age of an adult social care worker is 44 years - 9% are aged under 25; 65% aged 25 to 54; and 27% are over 55 years old. We estimate that around 15% of the adult social care workforce is made up of women under 30. This group may be particularly vaccine hesitant and thus could be more significantly affected by this policy. 

To encourage voluntary vaccine uptake in younger people, and therefore reduce negative impacts, communications to adult social care have been targeted to address specific concerns of staff. They have highlighted the potential benefits of receiving the vaccine to colleagues, service-users and patients, as well as to one’s own family. These communications have included videos from care home workers, blogs sharing best practice for encouraging staff uptake, stories of staff who have overcome their own hesitancy, and first-person video diaries of staff getting vaccinated. 

Religion or belief

We have no data on the numbers in the social care workforce who follow religions or hold beliefs that may make them reluctant to take the COVID-19 vaccination. (See section on ‘Religion or belief’ for the healthcare workforce for wider considerations around this protected characteristic)

Marriage and civil partnerships

(See section on ‘Marriage and Civil Partnerships’ for the healthcare workforce)

Pregnancy and maternity

As previously mentioned, the social care workforce is predominantly female. (See section on ‘Pregnancy and Maternity’ for the healthcare workforce for wider considerations around this group)

Race

Workforce data from Skills for Care shows a diverse range of ethnicities across the care sector. 1 in 5 members of the social care workforce are Black, Asian or from another ethnic minority, a higher proportion than in the overall population of England, in which 1 in 7 (14%) are Black, Asian or another ethnic minority. Black African and Black Caribbean staff comprise 12% of the adult social care workforce, compared to 3% of the overall population.

Some of the impacts of COVID-19 vaccination as a condition of deployment could be mitigated by ensuring culturally and linguistically appropriate materials about the COVID-19 vaccine are available in social care settings. Targeted communications and working in partnership with community leaders and sharing personal stories of social care workers from ethnic minority groups receiving the vaccination are also helping to build trust and drive vaccine uptake. However, there is a risk that issues such as lack of trust could be exacerbated by this policy. There is likely to be a significant effect on this cohort regardless of mitigations carried out.

We intend to publish our Public Sector Equality Assessment as part of the response to this consultation and will carefully track the impact of the policy on vaccine uptake, should it be implemented.

1. Lopez Bernal J, Andrews N, Gower C, Robertson C, Stowe J, Tessier E and others. ‘Effectiveness of the Pfizer-BioNTech and Oxford-AstraZeneca vaccines on COVID-19- related symptoms, hospital admissions, and mortality in older adults in England: test negative case-control study.’ British Medical Journal 2021: volume 373, n1,088 ↩

2. Lopez Bernal J, Andrews N, Gower C, Stowe J, Tessier E, Simmons R, and others. ‘Effectiveness of BNT162b2 mRNA vaccine and ChAdOx1 adenovirus vector vaccine on mortality following COVID-19.’ PHE Preprints 2021 ↩

3. Pritchard E, Matthews PC, Stoesser N, Eyre DW, Gethings O, Vihta K-D, and others. ‘Impact of vaccination on SARS-CoV-2 cases in the community: a population-based study using the UK’s COVID-19 Infection Survey.’ medRxiv 2021: 2021.04.22.21255913 ↩

4. Hall VJ, Foulkes S, Saei A, Andrews N, Oguti B, Charlett A and others. ‘COVID-19 vaccine coverage in health-care workers in England and effectiveness of BNT162b2 mRNA vaccine against infection (SIREN): a prospective, multicentre, cohort study.’ Lancet 202 ↩

5. Shrotri M, Krutikov M, Palmer T, Giddings R, Azmi B, Subbarao S and others. ‘Vaccine effectiveness of the first dose of ChAdOx1 nCoV-19 and BNT162b2 against SARS-CoV-2 infection in residents of long-term care facilities in England (VIVALDI): a prospective cohort study.’ Lancet Infectious Diseases 2021 ↩

6. Menni C, Klaser K, May A, Polidori L, Capdevila J, Louca P and others. ‘Vaccine sideeffects and SARS-CoV-2 infection after vaccination in users of the COVID Symptom Study app in the UK: a prospective observational study.’ The Lancet Infectious Diseases 2021 ↩ ↩²

7. Lopez Bernal J, Andrews N, Gower C, Gallagher E, Simmons R, Thelwall S and others. ‘Effectiveness of Covid-19 Vaccines against the B.1.617.2 (Delta) Variant’. New England Journal of Medicine 2021 ↩ ↩²

8. Stowe J, Andrews N, Gower C, Gallagher E, Utsi L, Simmons R and others. ‘Effectiveness of COVID-19 vaccine against hospital admission with the Delta (B.1.617.2) variant.’ 2021 ↩

9. Harris RJ, Hall JA, Zaidi A, Andrews NJ, Dunbar JK, Dabrera G. ‘Impact of vaccination on household transmission of SARS-COV-2 in England.’ Public Health England 2021 ↩

10. Wilde JA, McMillan JA, Serwint J et al. (1999) Effectiveness of influenza vaccine in health care professionals: a randomised trial. JAMA 281: 908–13 ↩

11. Stowe, E Tessier, H Zhao, R Guy, B Muller-Pebody, M Zambon, N Andrews, M Ramsay, J Lopez Bernal ‘Interactions between SARS-CoV-2 and Influenza and the impact of coinfection on disease severity: A test negative design’ International Journal of Epidemiology, 03 May 2021 ↩

12. Benowitz I, Esposito DB, Gracey KD et al. (2010) Influenza vaccine given to pregnant women reduces hospitalization due to influenza in their infants. Clin Infect Dis. 51: 1355- 61. ↩

13. Eick AA, Uyeki TM, Klimov A et al. (2010) Maternal influenza vaccination and effect on influenza virus infection in young infants. Arch Pediatr Adolesc Med. 165: 104-11. ↩

14. Poehling KA, Szilagyi, PG, Staat, MA et al. (2011) Impact of maternal immunization on influenza hospitalizations in infants. Am J Obstet Gynecol 204: [6 Suppl 1.] S141-8. Epub Feb 23. 2011 Jun. ↩

15. Zaman K, Roy E , Arifeen SE et al (2008) Effectiveness of maternal influenza immunisation in mothers and infants. N Engl J Med 359: 1555-64. ↩

16. NHS workforce data references data published by NHS Digital showing monthly numbers of NHS Hospital and Community Health Service (HCHS) staff working in NHS trusts and CCGs in England (excluding primary care staff). GP workforce data references data published by NHS Digital about GPs, Nurses, Direct Patient Care and Admin/Non-Clinical staff working in General Practice in England. ↩

17. Registered providers of the regulated activity of providing accommodation for persons who require nursing or personal care in a care home should not refer to this section of the Code insofar as it relates to requirements regarding COVID-19 vaccinations. Such registered providers should instead refer to the section of the Code which deals specifically with the requirements placed on them regarding COVID-19 vaccination in care homes ↩

18. NHS workforce data references data published by NHS Digital showing monthly numbers of NHS Hospital and Community Health Service (HCHS) staff working in NHS trusts and CCGs in England (excluding primary care staff). GP workforce data references data published by NHS Digital about GPs, Nurses, Direct Patient Care and Admin/Non-Clinical staff working in General Practice in England. ↩