Let us start with the verdict to date, where the NAO’s judgement chimes happily and almost entirely with The King’s Fund’s recent report on the vaccine roll out.
One thing we could not do but the NAO can do is judge value for money. According to the NAO, the biggest and most complex vaccination programme in the NHS’s history cost £5.6 billion up to the end of October 2021, with a mere 4 per cent of doses estimated to have been wasted – far lower than the initial planning assumption of 15 to 20 per cent. Given the scale of the operation that was still 4.6 million unused vaccinations. But 1.9 million of those were due to doses of the AstraZeneca vaccine that were already out in the field having to be written off after the Joint Committee on Vaccination and Immunisation recommended that it should preferably not be used in those aged under 40.
The initial planning assumption, based around the best of the flu campaigns, was that 75 per cent of the adult population would take two doses. The NHS, however, met virtually all of the more stretching targets it was set, with 85 per cent of adults having received two doses by the end of October 2021. ‘An effective use of public money’, the NAO says.
Its report provides similar qualifications to the roll-out’s overall success as our study. Despite significant effort, coverage remains lower than the average among some ethnic minorities, among the most deprived communities, and among the youngest cohorts – between 64 and 68 per cent uptake for those aged between 18 and 29 at the end of October 2021. The initial decision to use only the school vaccination service for 12–15-year-olds was an error – up to the end of January only 58 per cent of them had received a first dose. Some immunocompromised people experienced barriers in accessing a third dose.
Despite those qualifications, however, the vaccine programme has largely been a success, preventing hundreds of thousands of hospitalisations and more than 100,000 deaths. But neither Covid nor the vaccination programme is over. Big challenges remain.
The NAO chiefly takes the end of October 2021 as the cut-off point for the most detailed part of its study. Since then, in the face of the much more infectious Omicron variant, the NHS has responded to the impossible target that Boris Johnson set last December of a million doses a day with a big surge that hit a seven-day average of just over 750,000 doses, most of them boosters. But since the middle of January, the daily numbers have declined despite more than 1.8 million vaccinations being given since then – a mix of boosters and third doses, second doses, first doses in children and a continuing and encouraging trickle of adults still getting their first dose. That still leaves an estimated 3 million or more unvaccinated adults. Yet the government is doing little actively to promote the programme at a time when an estimated 1 in 30 in England have Covid.
In other words, there is too great a sense that Covid is over. There will be other variants, maybe more mild, maybe much nastier. The ONS surveys show that the effectiveness of the vaccines is holding up well. But fifth doses may well be needed – on top of the fourth dose that is already planned for over 75s and some others. So the challenge, as the NAO points out, is how is the Covid vaccine going to become business as usual?
As is well known, in the interests of saving lives and keeping as much as possible of the hospital service still operating, the vaccine took precedence over some other parts of NHS activity, particularly in general practice. Up to the end of October, GPs had delivered 56 per cent of vaccinations and pharmacies another 15 per cent, excluding boosters. But, as the NAO notes, there is the issue of staff burn out. Many GPs and indeed pharmacists and others worked extraordinary hours to make the roll out work, and that cannot go on for ever.
So who will do the vaccinating? The government, with the support of organisations such as St John Ambulance, trained some 80,000 additional vaccinators, not all of whom were used. Should these people be on standby for a fourth or fifth dose? And, in which case, how should they and the army of retired clinicians who also helped, be retained and be paid? How might they be organised? Where do they fit with the ‘reservists’ that the NHS England chief executive announced earlier this month? Will the eventual decision be that additional boosters simply get given along with the flu jab? Or will the population that will need boosters be larger than those who normally qualify for influenza protection?
A new, nastier variant, would definitely require the latter. The government ordered an additional 114 million doses of the Pfizer and Moderna vaccines after the Omicron variant arrived which may – or may not – be more than needed. So plans are needed about what to do if not all of them are required. For example, there are vast numbers still unvaccinated in the less developed world, but both these vaccines have higher cold-chain requirements than the AstraZeneca vaccine and so redistributing them might prove challenging.
All this is tough stuff. It requires some serious scenario planning, and the ability to flex when circumstances change, as they may do rapidly. Not easy. But necessary.