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

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

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

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

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

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

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

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

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

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

Greg has stolen my thunder.

I was going to say that this is your bag.

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

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

One important milestone is the delegation of responsibilities to ICBs.

Just give me a number.

Two years.

Two to three years, with an evaluation in between.

Ditto.

Two to three years.

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

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

Would you accept it is a risk?

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

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

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

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

Who will have done those impact assessments?

I would hope it is at ICB level.

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

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

Yes.

Understood.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

You were nodding, Ben. Do you agree?

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

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

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

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

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

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

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

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

I will try to be polite.

No, you do not have to be polite.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

So more money to pharmacists?

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

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

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

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

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

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

We are going to come to this.

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

If I keep talking, the Chair will have me.

She will.

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

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

That might be a mistake that you should reflect on.

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

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

I do not know. That is my short answer.

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

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

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

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

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

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

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

I would still agree. I stand by that.

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

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

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

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

I agree. It is actually pretty helpful.

In what sense is it helpful?

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

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

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

Where would you want to escalate it to?

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

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

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

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

Broadly, yes.

But it is not at the moment?

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

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

Yes.

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

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

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

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

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

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

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

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

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

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

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

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

Thank you very much. We will stop there. Thank you all for your time. Witnesses: David Lamberti, Dr Mary Ramsay, Michelle Kane and Annie Traynor.

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

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

I am director of vaccination and screening for NHS England.

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

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

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

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

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

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

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

We are making progress.

So on target?

We are making progress.

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

There was not a target.

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

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

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

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

Some yes, some no, basically?

Exactly.

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

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

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

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

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

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

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

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

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

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

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

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

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

They were removed from the planning guidance.

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

What effect has removal from the planning guidance had?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We do not have a date and a target.

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

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

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

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

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

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

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

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

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

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

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

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

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

I am very happy to.

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

Not overall.

Not overall?

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

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

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

The health system what?

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

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

There is no study that does what you describe.

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

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

Will you look at it?

I am very happy to try.

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

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

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

They can. There are—

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

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

GPs might be annoyed if pharmacies can do it?

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

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

We are piloting some of those—

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

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

Where are you piloting them?

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

You are not piloting MMR?

No, but we are piloting other vaccines.

I asked you about MMR.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yes or no is sufficient.

We will take the question away and come back.

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

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

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

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

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

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

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

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

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

The flu walk-in finder.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What is going to be different?

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

So let us see if it actually comes forward.

It would help to give an ICB perspective. The role of ICBs is going to increase in this space over the next year. We will be playing a more active role in working with our local providers. We will be around the table with the school-age immunisation service to plan that intervention. One of the issues around the start date—ours started on 15 September, so in pretty good time, although we would have liked it to have been 1 September, and it was to do with vaccine supply—is that co-ordination is sometimes needed with the schools. There are sometimes operational planning difficulties, but they are the sorts of things that we, as a health system, can overcome by working with our local authority colleagues. It is much harder for a remote commissioning team such as NHS England.

That is great to hear. My concern is about variability across the country. I am sure Leicester, Leicestershire and Rutland is charging along on many things, but there is variability. From a national point of view, what I want to hear—as my colleague just said—is that we are going to see a target of 85% coverage, whereby 85% of schools are going to finish by the end of November. Are you going to set yourself a target for that to be an actual thing nationally?

What we are looking at doing is making sure that, in pulling forward the end date, we have time before the Christmas break to do second or catch-up visits for those kids who may not have been at school the first go round.

We will definitely be following that.

But you do not have a target. I am sorry to pick up on that but I want to press on this because it came up earlier as well. You do not have a target for the percentage of schools in which this should be effective by this time next year.

We do. Every year we expect every school to have had a visit.

Your target is 100%?

Yes, but we are pulling it forward, so we have even more time to do second visits or catch-up clinics in communities to make sure every kid gets the opportunity.

By the time we get to next winter, we expect the digital system Michelle was describing to have been rolled out across a lot more providers and be in a lot more schools.

We expect miracles, David. We expect fabulous things, and we will look forward to hearing all about it. We are going to move on to frontline healthcare staff, an incredibly important target group. Having been a frontline healthcare worker myself, I am absolutely astounded that the vaccination uptake remains so low. On average, it remains below 50%, at about 41%, and there is variation across the country. If I look at the data in front of me, I can see that vaccination rates are lower than one in five at 21 English NHS trusts. At West London NHS Trust, Croydon Health Services NHS Trust, and Birmingham and Solihull Mental Health NHS Foundation Trust, the uptake was at one in 10 or lower. This seems to be a place where we should urgently be putting resources and all our brainpower. What is happening, and how are we going to get these rates up?

Can we talk about this year, and then we will talk about the future?

Please do.

In the context of continuing decline, we need to stabilise and build out of that.

Why is it declining? What is going on?

There are a couple of things going on. We are still hearing noises around reaction to vaccination as a condition of deployment. That was brought in during the pandemic when it was mandated through the covid vaccine. We are all well rehearsed on the impact that had both in terms of how staff felt about it and the trust staff had at the same time. That is definitely continuing to play a role. Thinking about what has happened this year, we are now knocking on the door of 48% uptake, but I agree with you that it is not where we want it to be.

The variation for those trusts that are less than one in 10 is absolutely outrageous.

Absolutely. We need to build on what has worked this year. Every trust was required to have executive leadership that was accountable and responsible for ensuring maximum uptake across their NHS trusts in staff vaccination.

Do they have targets to hit?

Yes.

What happens if they do not hit those targets?

A couple of things. They have lots of lean-in conversations to understand what is happening.

A lean-in conversation does not sound particularly serious. Is there anything else?

On the published data, it is really important to know if there are challenges in terms of how that data is collected. It might be inaccurate. It is about having a conversation in partnership to understand what is going on in the space.

I take it that there is always variation in data. However, across the entire country we are getting a fairly standard picture that variability is much reduced because of the large collection here. We can say that, within a confidence interval, we are reasonably clear that this is still not an acceptable amount. We are having lean-in conversations with people and we are going to have executive leadership. There is going to be a target that they have to hit.

There is a target.

I do not know if you want to come in, Annie. What is going to make a difference? Why are my healthcare colleagues not getting immunised? What is going on?

With all these challenges you are making around why levels are not increasing, we need to recognise that time is needed. I know it is urgent, but we need to reap the benefits of the changes that are being introduced now and—

A gentle challenge there. I absolutely hear you on time. I am a public health consultant and things take time. However, during the pandemic, things did not take time. We simply went out and did it. I would argue that this is a similar issue, and we should just go out and do it. What are the blockers?

There is a practical reality. Frontline workers are busy, and they are under a huge amount of pressure doing their day job. The reason why we have seen a nine percentage point increase in our uptake in our two trusts this year is that they changed the delivery model.

Is availability again a problem?

Covid drove the trust to a model of clinics. The staff had to go to the clinics to get vaccinated. Covid is no longer offered, and those clinics do not exist any more within the hospital setting. They have created roving teams again, so returning to the peer-vaccinator model. There are now around 180 peer vaccinators in our acute trusts who have taken the vaccine on to the wards. We believe that has fundamentally had the biggest impact. Other soft incentives have been given to staff. For example, they can have a hot chocolate and get vaccinated.

I understand all that. Do you think this is being prioritised sufficiently within our National Health Service? When the ICB and chief execs of trusts sit there and talk about getting waiting lists down, pressures, bed blockers and so on, is this a fundamental part of their prioritisation? I appreciate that it is subjective and you are talking for various people, but what do you think?

Two things on this one. Having it as part of the joint planning for winter, joining it up with where people’s heads are at in terms of ambulance handovers and four-hour delays has been really powerful this year. Considering it in the round of winter pressures, yes. The second is having a named executive within the trust and the ICB, which is something that came out of your report. These people have been in place for two years now. Having focused conversations about vaccination, and I am talking specifically about staff here but in the round, is incredibly important at that top table.

I am going to have to leave it; I could talk to you for hours.

That leads quite neatly on to my set of questions around vaccine hesitancy. You spoke about the building trust model among healthcare professionals. What are the most significant lessons learned from the covid-19 vaccination programme that you are carrying forward to address vaccine hesitancy and improve public trust?

It is a great question. When talking in the round, at a macro level, sometimes examples really do get lost. It is exactly what you have just described: starting where people are and not where we want them to be. The NHS vaccination strategy is quite clear. What we need to do is build on the core offer, which, talking to Mr Coleman’s point, sometimes does not work for everybody but we cannot throw the baby out with the bathwater. We have GP practices, school-age immunisation services, and community pharmacies offering vaccines in those buildings in a way that is traditional. So how do we build on what we know? Over the past two years we have created an access and inequalities fund that goes directly to the system to support the continuation of some outreach work that was so effective in the pandemic.

Specifically, how is that addressing hesitancy?

It is about going out and talking to communities. It is about engaging with people in a way that makes sense to them, so things such as “train the trainer”, engaging with community leaders, faith leaders, and community activists to empower them in terms of engagement around vaccination. It is about understanding drivers of hesitancy so they can have those peer conversations in a way that makes sense in their own local area. That is one example.

What specific measurable accountability metrics do you have to prove that this is successful?

It comes back to the flexibility open to local areas, so working through traditional commissioning routes. For example, we have seen some really great initiatives for MMR uptake in places such as Leeds, including working with schools with the lowest uptake for six to 11-year-olds and working with community champions to have meaningful conversations with parents at the school gates. We have seen 200 vaccinations offered on the back of that, with people coming forward to take up the offer in a way they would not have otherwise.

Are you specifically tracking areas where you have previously seen levels of vaccine hesitancy to see if some of the misinformation and disinformation is dying down?

We have a national survey that we run every year, which monitors attitudes. We have been running it for 30 years. It is a market research-type approach, but we have had to change methods more recently. It is not always comparable, but it does track the level of trust that parents have overall in immunisation. Overall, the message is good. Most parents trust immunisation; they think it is important and safe but there has been an increase in negative messages being picked up through social media. That is hardly surprising. We have all known that. What is reassuring is that, when you ask parents who they trust to go to for information, it will be healthcare workers first and the NHS. Social media and the internet are very low. Obviously, it does not mean you do not have that influence. The big message is that it is really important that the frontline healthcare workers are able to reinforce the right messages to explain things, so training healthcare workers. There are various issues about how you have those conversations as well. We have made a big effort on that but it does need to be done more.

The question is how are you tracking what interventions are successful? For example, one learning from the covid-19 pandemic was that behavioural scientists did not use nudge techniques enough. Are you looking at behavioural science? Are you looking at ways to nudge? How are you tracking what works?

That work is one element of behavioural science. We have a behavioural science insights unit in our team, and there is one in the Department. We work with the London School of Hygiene and Tropical Medicine and others. The survey looks broadly overall. Obviously, there are issues in specific populations, and you can only do that work locally. We are encouraging ICBs and local directors of public health to do a lot of that work. You cannot see it as looking at attitudes on your own; you have to see how you can then design the intervention to support a response to it. Those various techniques are called tailoring immunisation programmes. It is a WHO technique that we are encouraging local areas to take. You go in and look at a particular area. You see what the attitudinal and access barriers are and try to put them together. So it is important not to separate them out.

Access and confidence are two sides of the same coin. Are you tracking which interventions are successful?

One thing that is really important is that these things are evaluated. They often tend to get introduced then stopped quite quickly, so sustaining these things is really important. In order to sustain them, because they require extra resource, and some outreach approaches are very expensive, we have to evaluate them. So we are trying to build evaluation into that.

Can you give me an example of an approach that you have tried? You have evaluated it, it has been successful and has been rolled out. We had a very good example in the first panel of engagement with an Orthodox Jewish community, but there was a cost there.

We worked with the London School of Hygiene and Tropical Medicine on that, and it was successful. Unfortunately, the pandemic threw a lot of stuff around. We have not done as much as we should have, but one thing in our equity strategy is about local teams not just doing the work but evaluating it and then hopefully sustain it.

Do you have an example of a programme that has been sustained?

Not specifically on attitudes, but the offer of vaccination in schools has been sustained and really successful. If you can offer vaccines in school, that will make a huge difference. I am talking about the MMR catch-up. If you have missed your MMR, you can come to school and get the offer there. That makes a difference. It can be sustained and is sustainable. Wales has done that and has increased coverage by a few per cent on MMR.

I am trying to get around that hesitancy but not necessarily the access, because there are examples of widening access.

It is a very dynamic area.

I can give you a very local example. We secured some access and inequalities funding from NHS England last financial year. We used it to establish a local immunisation street team. We put that team into areas where there were high levels of deprivation, low uptake and high numbers of measles cases. We used that funding to work with voluntary and community organisations and our outreach provider to take vaccines into the community in other settings. The team also worked closely with the GP surgery. The GP sent text messages to the community to say, “There is a roving vaccination vehicle in the area today, alongside a number of voluntary and community organisations that the community are familiar with. Come along. It is free. No appointment is necessary.” It was put on in the school holidays, and it was near a food bank. In the period that the project was running, we saw a 10 percentage point increase in our MMR uptake. It is a very specific example in a small community, but we are now trying to find out how we can use that model in other communities. At the moment, the challenge we have is that the money is short-term. We do not know whether we are going to get it in the next financial year. If we want to see sustained improvement in tackling health inequalities and vaccination delivery, we need long-term funding. It is great to hear that there is now a three-year commitment, but that has not yet been communicated to ICBs. What we need to know is that there is a three-year plan for that funding because we can then start putting contracts in place and ensure that we get those providers mobilised.

Is there anything in place to monitor levels of disinformation and misinformation on a wider scale, and a strategy to counter that? Community groups are fantastic at a granular, local level, and I appreciate your being able to provide that example. On a wider level, what people are picking up from social media perhaps or—

There are various academic listening services that look at these things. The WHO has one, UKHSA has one, and I suspect DH does to some extent. The issue is how you respond and the risk of over-responding. One thing we do not want to do is drive people to become anti-vaccine. We have to make sure that, when people have that conversation, a healthcare professional can help to dispel the myths. They can help them explain the pros and cons of vaccination and they can have that proper conversation, which you cannot have on social media. In responding in the social media, and we do some of that, the danger is that you direct people towards the anti-messages.

What is driving that lack of confidence among health professionals? That is another question leading on from my colleague’s question earlier.

There has been some work in this area which shows that, if you train them, it improves their confidence. That is a big thing. It is about them having access to training, being able to get time off to train, and good-quality training being available locally. We do not have a really good grip on what is going on locally. There are some excellent trainers out there but we do not know if everybody is getting access to them. That is one thing we want to try to improve over the next year or so.

Briefly, are you measuring hesitancy among health professionals on getting things such as the winter flu vaccine? How are you tackling it?

We have done attitudinal tracking among healthcare workers. We do not do it every year, because it requires funding. I cannot remember the last time and the next time, but I can look it up and come back to you.

A few follow-up questions. When are ICBs going to be told officially that they are getting three years’ worth of funding?

I do not know the answer to that question.

Can you write to us?

Yes.

Was this an announcement? Was this new? Did you know this?

I was not aware that there was a commitment to three years’ funding.

Good news for you.

It is a three-year settlement for the NHS, and I will have a conversation with Michelle about how we view the money that goes to vaccines and screening.

So it may not be three years. Write to us with more details please because it strikes me that it is quite important. I have a quick question for Michelle. If you received the flu vaccine a month earlier, what could you do with it?

We can mobilise in the timeframe that is required. We are planning for this year now and will be advised by the specialists in this area as to when is best to vaccinate, so I would defer to Mary and colleagues at JCVI.

Is it useful to get it earlier?

For some groups but not all. It goes back to what we talked about earlier. You have to have protection. The protection wanes within the season, particularly in older people. Vaccinating—

We are talking about the delivery of it, not receiving the vaccine; it is not the same thing.

Having the system armed will help you deliver when you are ready to. Yes, it would be helpful because you do not then have to wait for the distribution. You have to bear in mind that you do not want GPs with their fridges full of flu vaccines that means they cannot store other stuff. We have to have an agile system, which we have, but those are the things that we—

Is there more the industry can do to help you be better prepared?

Having the flu vaccine earlier, knowing when it is going to be available, and being able to say confidently that it will be there in week one of September would be really helpful.

What message would you give to the industry at large? The ABPI is in the room and can relay this to the right people. What needs to happen for you to have that—

It is a combination of regulatory and production issues. These are biological products, and batches occasionally fail. That has been very rare recently. They are now much more robust because we use vaccines that are made in more technically advanced ways that are a little less risky. That has not been a problem in recent years. Obviously, we would like them to produce the vaccine in the volumes we need as early as possible so that we can start planning for that.

Is there more that needs to happen in this place or the Department to help them to do that?

No, the understanding is there.

The regulatory system is functioning to the expected timescales. We are getting better and better at doing trials in this country. We are in a decent place in terms of how that system is working.

I came here today with the conclusion that the vaccine programme was not working. I hoped to finish the session feeling completely reassured that I was wrong. We were told in panel 1 that we might have been a bit fast to jump the gun, and that we should wait two or three years. I am going to be perfectly honest with you and do something I do not normally do. I am not convinced that, in two to three years, the Department and wider will have a grip on this. In fact, the conclusion I am coming to is that the system—not individuals, I appreciate that—does not have a clue what success genuinely looks like and that good actually means just not worse and maybe a bit better. Tell me I am wrong, and be specific about why.

We want to get back to the levels set by the WHO; that is clear.

Could you give us a timeline?

As soon as possible. We do not have an analytical basis for giving you a date at this point, so we would be making that up.

A smart target, with a timeline and specific milestones, sets the pace in a system. That is why I am not reassured. In fact, the word that has come to mind over and over again during the last hour or so is “complacency”. Not individuals, but the system feels complacent to me. Yes, we want to do better. Yes, we all feel this. We are here. I am sure you, as individuals, are here because you care about this. No doubt, that is why you applied for the job in the first place, but the system feels complacent. Where are those targets? Why do you not have them? Is it the Secretary of State who needs to set them? Help us here.

Analytically, we do not have a target and a basis for a timetable. I cannot give you a different answer to that today. In terms of our passion for increasing the capacity and capability of the system, it is there and we are acting on quite a lot of fronts. What we need is a sustained effort on all those over time: fixing the core offer and getting outreach to work. Annie has been describing great examples of how that can work locally. These things, taken together, will get us to a better place and we are confident that those are the right things to be doing. At the moment, I do not have a position agreed with Ministers on a timetable to give to you.

So we can push Ministers if we have a concern with that. Mary, can you help me out here? Do you understand what I am saying?

Completely. I just want to say that there are some really good things about our programme. We have a really good programme in terms of what we offer, when we offer it and how quickly we introduce new vaccines. We should not lose sight of that. Coverage is the bit that has been declining. That has been a challenge globally, but anything you can do to help prioritise it so that local action can happen would be helpful. We know what works; it just needs to actually happen.

What is the biggest barrier to it happening, in your eyes?

Changing the system, I am afraid. We are still recovering from the pandemic, and there is still more change to come. We need to get on top of it while everything else is moving.

The constant changing of the system. I will press you into that little rabbit hole for a second. Is it the change to ICBs or—

No, it is the stability of primary care. That core offer is really important.

Michelle, help me here.

I am going to help you. I have a couple of things on this one, but I will be quick because I am conscious of time. One, I do not think this strategy is a failure. It has very solid foundations that we can build out. Two, the progress we have made on the strength of leadership and visibility shown this winter, by joining together and making vaccination everybody’s business in terms of winter planning, has been powerful. It has been a powerful signal to the system and we need to see more of it. I am confident that we can see more going forward.

This is what I mean about more. More from a base that has been declining, stopping it going down. This is not what I want to hear. I want to hear that in two or three years’ time, once it has had time to bed in, you will have hit “insert target here” which equals success. What is that target? In your own mind, do you not have a personal view about that?

I have a personal view.

You do not have to tell me what it is, but why is the system not taking on that view and setting a clear target for what success looks like?

We need to be collectively ambitious, because this is an incredibly important agenda. It goes back to where we started with Danny’s question around being clear about the target. Let us be clear about who is accountable for the delivery of it, and let us be clear about how we are going to get there. We started with the vaccination strategy, underpinned by a 95% uptake expectation with a clear trajectory to recover. Who is going to be held accountable for that at a national level, and in local systems as well? We have made good progress in terms of executive leadership within hospitals and within ICBs. We need to make sure we maintain a national focus at the same time.

The view from the centre, and we kept hearing it from the Secretary of State and others, is that national does not want a target but ICBs should have one. It should therefore be up to local systems to drive this. Annie, you are clearly a good example, hence why you are here, but are you getting what you need in order to set these ambitious targets or are you saying, “We are making some progress and they are off our backs?” Where is your head in terms of this?

We need five years.

You need five years, not two or three?

We need five years of sustained additional investment. It is great to hear that we have a three-year plan, and I would be really keen to see what that looks like. About 1% of our funding is in place to tackle health inequalities. The rest of the funding in place for immunisations is being used for the universal programme. We need around 10% of funding to support health inequalities to pick up those levels.

It is your budget.

It is not currently.

But in the new changes it will be.

There is an important milestone, which is April ’27, when ICBs become commissioners. That will be a step change, because we will then be directly determining how that resource is being used for our population. What I would add is that we need more. I do not think it is just about redirecting and reallocating the money that we currently get. There needs to be new investment in health inequalities for the long term of around 10% of the budget that we currently get.

Would you like to see that ringfenced?

Absolutely.

You would like ringfenced budgets for inequalities?

I would argue for health inequalities to support prevention, not just health inequalities to support immunisation. Our long-term vision is about having integrated outreach prevention services that target those key communities that we just cannot get to currently. The universal offer is strong. There are some issues around improving performance and access. That will happen. It is known, it is understood. We just need time to get beneath the surface and start making those improvements. I am being honest in saying this is at least five years. What you can do to help us is raise the profile. At the moment, the 10-year plan talks about prevention. There are very few references to vaccination. In fact, there are more references to the tailored cancer vaccines for individuals than there is for the routine vaccination programme. I was really disappointed when I read the 10-year plan, to be honest. It did not get the message across to the public how important primary prevention is within the prevention agenda. That would be my plea to you; help us get the profile up so that it is on everybody’s radar.

That is a very good place to end. Thank you very much.