What next for the UK’s COVID-19 vaccination programme?

The UK vaccination programme so far

As of 24 February 2021 the UK had given a first shot to 28% of its population; no other European country had managed more than 5%. The government’s ambitious targets for 15 February were met, with over 15 million people vaccinated, and virtually everyone in the four highest priority groups offered a vaccine. The UK is on track to vaccinate all those older than 50 by early May (see the chart below), and for all adults to be offered the vaccine by the end of July.

However, while the programme is broadly a success, questions and challenges remain: about how quickly the programme translates into reductions in deaths, hospitalisations and cases; in ensuring all people have equal access to (and uptake of) the vaccine; and in the ability to continue to ramp up supply and delivery – particularly given the need to offer second doses. Here we provide some insight into each of these questions.

Challenge 1: The effect on deaths, hospitalisations and cases will be (initially) slow

The government’s 15 February target was a promise to offer a first jab to the 15 million highest-risk individuals – not a promise to vaccinate everyone, nor a promise of maximum benefit (which would require second doses to have been administered). This and the lag between vaccination and an individual developing immunity, means it will take time to see clear changes in the main metrics we use to track the pandemic: cases, hospitalisations and patients in critical care, and the number of deaths.

In addition, the degree to which the vaccine will affect each of these metrics will vary – primarily due to who is being vaccinated. Deaths from COVID-19 are primarily among people aged 70 and older – many of whom are now vaccinated – so deaths should fall quickly. Cases are more likely to be among younger people – change will therefore be slower here. The chart below shows the share of deaths, hospitalisations and cases by age, based on data from England.

1. Number of cases. This will be the last metric to be strongly affected by the UK’s vaccination strategy – primarily because most cases and the spread of COVID-19 are among those younger than 50, while almost all vaccinations until May will be those older than 50. Though vaccination will avoid some cases immediately (for example, we would hope to no longer see outbreaks in care homes), the majority of any immediate declines are likely to be caused by the lockdown.
2. Number of hospitalisations and patients entering critical care. These two metrics are central to the NHS’s ability to cope and, thus, our ability to exit lockdown safely – but the impact of the vaccination programme will be different on each. Patients in critical care are primarily younger (nearly half are younger than 60, fewer than 5% are older than 80), whereas overall hospitalisations are primarily of older people (two-thirds are older than 60; a third older than 80). We can therefore expect hospitalisations (especially if we look specifically at those in their 70s) to begin falling; critical care capacity will take much longer to recover.
3. Deaths. This is the metric that should be most quickly affected by the vaccination programme, as those older than 70 account for 84% of the deaths from COVID-19 (this rises to 88% for all those in the top four priority groups). Because we do not know how many deaths there would have been had we not had a vaccine, assessing the precise effect of vaccination on deaths (and in particular the difference between one and two doses) is difficult. Falls in the number of deaths cannot just be attributed to the vaccine. One approach being taken is to compare the reduction in deaths among those in their 80s with the reduction in deaths among those aged 60–69, the majority of whom have not yet been vaccinated.

Challenge 2: Unfairness in vaccine distribution and uptake will create and exacerbate inequalities

We have long known that the inverse care law applies to accessing health care in the UK – those that most need care (such as those from deprived areas) are often the least likely to be able to access it. We also know that COVID-19 has disproportionately affected individuals from certain minority ethnic groups, and from more deprived areas – and that these groups tend to be more vaccine-hesitant, and can find it harder to access health services.

The Joint Committee on Vaccines and Immunisation’s (JCVI) prioritisation advice to the government is largely based on age, because the risk of death increases with age. Clinical risk is also taken into account (the ‘clinically extremely vulnerable/shielders’), with the NHS’s new model for this (released on 16 February) also accounting for an individual’s socioeconomic background (via their postcode) and ethnicity.

Within age groups, the NHS is trying to ensure that all people – regardless of deprivation, geography, or ethnicity – have equal uptake of the vaccine. This is important not just from an equity perspective, but for practical reasons too – until protection is widespread, we all remain at risk. However, despite this approach, early data suggests that inequalities are emerging.

Socioeconomic deprivation

Those who live in the most deprived areas are less likely to be vaccinated than those who live in the wealthiest areas, despite being at greater risk of death.

More deprived areas of the country have younger populations: around 15% of the population of the richest decile in England are older than age 70, compared with around 8% of the population in the poorest decile. This is partly a result of the effects of deprivation on people’s health and length of life – we know that men in the most deprived deciles of the UK can expect to live 9.5 years less than those in the least deprived deciles, and women 7.7 years less. Vaccinating in accordance with the government’s age-based criteria would mean vaccinating more wealthy older people (because there are more of them) than poorer older people – even if uptake was equal between groups.

Early data from an OpenSAFELY study (based on a database of 23 million GP practice patients, around 40% of the total number) shows the number of 70–79 year-olds and 80+ year-olds vaccinated by quintile of deprivation, up to 4 February. For the group in their 80s, not only are there fewer people in the poorest areas but these areas have lower uptake too (70% in the poorest areas; 90% in the richest).

Lower vaccination rates in poorer areas is particularly concerning as we know that individuals from poorer backgrounds are around twice as likely to contract and die from COVID-19 as wealthier individuals. Using data on deaths from the first wave of the pandemic, the chart below shows how age and deprivation interact. If we vaccinated 100 80–84 year-olds in the poorest decile, we would save around 10 ‘life years’ (assuming vaccination prevents deaths of the scale we have so far experienced). If we did the same to 80–84 year-olds in the richest decile, we would save half as many – only 5 life years – this even though age is the primary driver of mortality from COVID-19.

If we wanted to allocate vaccines to all people who would equally benefit at the same time, we would vaccinate those aged 60–64 in the most deprived areas at the same time as the 70–74 year-olds in the richest areas. This would mean increasing the allocation of vaccines to more deprived areas. For example, allocating vaccines based on the number of people aged 70 and older means a 65:35 share between the richest and poorest groups.

There is of course a trade-off between ease of implementation and sophistication in targeting risk and achieving equality. The JCVI’s criteria took account of the most important determinant of risk – age – but left others for NHS England and NHS Improvement, the Department of Health and Social Care, Public Health England and the devolved administrations to identify and address in implementation.

Ensuring total equality and perfectly targeting risk is tricky but, as illustrated above, addressing the inequalities in access arising from deprivation could be achieved through guidance and tweaks to the way supply is allocated.

Ethnicity

People from minority ethnic groups seem to be less likely to access the vaccines, and less likely to take a vaccine if offered.

We know that people from minority ethnic groups have been disproportionately affected by the pandemic, with the death rate among black Britons four times that of white Britons, and Asian Britons 3.5 times. We also know that vaccine hesitancy has historically been higher in these groups. There are therefore widespread concerns that uptake of the vaccine among some minority ethnic groups might be lower.

Early data from the OpenSAFELY study seems to support this. Of those 80+, nearly 90% of white Britons have had their vaccination, compared with only 55% among black Britons. Despite this, the JCVI has no explicit plans to target or prioritise minority ethnic groups. The strategy for phase two of the rollout continues to follow age bands, with individuals from minority ethnic communities simply encouraged to 'promptly take up the offer of vaccination when they are offered', and some suggestion that deployment teams should use communications and outreach to promote vaccination in these groups.

Geography

Early analysis suggested some regions were vaccinating more quickly than others. Further analysis suggests the picture is more complicated than this.

News stories have often highlighted some geographical inequities in vaccine rollout – with London, in particular, appearing to lag behind northern England in vaccinating its population. However, more detailed analysis shows a more complicated picture. Sustainability and Transformation Partnership areas in major cities have vaccinated a smaller share of people older than 70 than elsewhere, but are doing comparatively well at vaccinating 65–69 year-olds. This is shown in the chart below – the lowest vaccination rates are in the five London STPs, two Birmingham STPs and Manchester STP – all major cities. These STPs are doing reasonably well in vaccinating the next age band down – 65–69 year-olds.

It is not yet clear what is driving this variation. The greater ethnic diversity of these cities could be one factor. Data issues could be another. These figures are based on data collected in the 2011 census. The census is 10 years old, meaning ONS must project what the actual population is – this is particularly challenging locally, where you need to take account of migration between local areas. For example, if substantial numbers of older Londoners have left the city (or, indeed, died of COVID-19, as around 2% of those older than 70 have), this will make it impossible to vaccinate 100% of the mid-2019 estimated population. 

We can also see this problem in the national figures. Chart 1 suggests that 100% of 75–79 year-olds have been vaccinated. This seems unlikely, and probably suggests that the ONS’s projection of the number of 75–79 year-olds in England is lower than it should be.

Challenge 3: The supply of vaccines and vaccinators will need to keep pace with demand

The government has been very tight-lipped on sharing information about the projected supply of Pfizer and Oxford/AstraZeneca vaccines – and we know that both companies had warned the EU to expect short-term shortfalls in doses. Without this information, it is hard to know both whether the current rate of vaccination of around 500,000 a day can be maintained, or even if it could be increased. Although supply has been a rate limiting factor, it is unclear to what extent workforce, space and time would be sufficient to deliver the vaccine.

The need to offer second doses

In February, England has been vaccinating at the rate of up to 2.4 million doses per week. 99.5% of these are first doses. By the end of March, the million people given their dose in the first week of January will have to have had their second dose; by late April, all of the 2.4 million given their first dose at the beginning of February will need to have their second dose.

If the dose rate averages 2.5 million doses per week, by the end of April all vaccination capacity will be focused on second doses. The next round of first doses will then start ramping up during June with everyone being offered their first dose by the end of July. Only by the middle of September will everyone 16 and older have been given two doses. To begin vaccinating new people the supply of vaccines will have to increase, as well as the capacity to deliver them. Given the government has now committed to offering a first dose to all adults by 31 July, we can assume that there is a level of confidence that supply will be sufficient.

New vaccines

Part of this increased supply will come from new vaccines. The UK currently has supply of two vaccines – Pfizer and Oxford/AstraZeneca – and has approved one more, Moderna (17 million doses are due to arrive in ‘spring’). Two additional vaccines – Novavax and Johnson & Johnson – recently reported positive findings from phase three trials, and could be approved within months.

These new vaccines could also simplify delivery. The Pfizer vaccine requires time-consuming preparation, and patients must be observed for 15 minutes following their jabs. A simpler, one-shot, easy to store vaccine like Johnson & Johnson’s could streamline the delivery process.

Having sufficient workforce

The vaccination programme is primarily delivered by NHS staff in primary and secondary care (with some pharmacies). Though some staff are volunteers or ‘returners’ (retirees who have come back to support during the pandemic), many are doing vaccinations either in addition to, or instead of, their day job. This risks burnout, and deprioritising other aspects of their role.

One practice, for example, told us how time intensive individually ringing their patient populations is. Staff were happy to do it, but also well aware they were falling behind on other tasks (such as ordering supplies) in order to do so.

Some aspects of the programme are likely to become more time intensive – in offering second doses, and in ensuring uptake among more hesitant groups. For example, to persuade the reluctant to take the vaccine at one major hospital, a vaccinator described daily lunch walks to individually identify, and talk to, unvaccinated staff.

Likewise, we might see individual GPs, perhaps in partnership with local community leaders, undertaking intensive work to reach certain groups. This takes staff time, and needs to be done on a highly localised level; it is not something that can easily be ‘outsourced’ to a major vaccination centre. However, as vaccination reaches younger age groups more able to travel (and, anecdotally, simply take less time than those in their 80s to progress through the clinic), mass vaccination centres will play an increasingly important role. This should take some pressure off primary and secondary care staff.

Being able to also offer ‘usual’ care

If practices or hospitals are running vaccination clinics, they may not be offering other care. For hospitals, at least currently, this is not having a significant effect on what other care can be provided – current restrictions mean that some parts of the hospital are less busy than usual, so staff can be redeployed.

For GP practices, this may be less true – some practices are running vaccine clinics for several days each week, simultaneously trying to maintain usual services with depleted staff. Again, the impact of this as we emerge from lockdown, and people’s use of the NHS returns to more ‘normal’ levels, may be significant. Of course, the alternative – not vaccinating people and a continuing uncontrolled pandemic – would have a far greater impact on the NHS’s ability to provide care.

Conclusion

The UK’s vaccination programme has delivered vaccinations at a higher rate than almost any other country in the world. Any programme rolled out at this scale and pace would be imperfect and not always be fair. But, thanks to its rollout by a system – the NHS – with the principle of equity at its core, the shortcomings of this programme, when weighed against its successes (and the failures of other countries), are relatively minor.

That said, there are new challenges ahead. Differences in vaccine uptake that may look minor on a local level multiply when echoed across a nation, and on top of a crisis that has already disproportionately affected those from minority ethnic groups, and from more deprived areas.

Planners should think carefully about which inequities are most important, and address these through policy and system design, including how vaccines are allocated to different parts of the country, and increasing uptake among under-served groups. For example, while it may be unfair that 80-year-old Londoners are receiving their vaccine a few weeks behind those in the north of England, it may be that the focus should be on addressing the systemic and ongoing lower uptake among more deprived populations, or certain minority ethnic groups. The latter is likely to require a substantial investment of time and in the workforce. Our conversations with front-line staff suggest it is people having conversations – NHS staff with their colleagues, NHS staff with the public, communities with each other – that shifts the dial on vaccine hesitancy.

Of course, equitable uptake requires sufficient supply. The ability to offer vaccines to ‘new’ recipients after April will depend on how quickly new vaccines are approved and manufactured, and on the ongoing success of current supply chains. The NHS is currently relying on a mixture of redeployed staff and volunteers to deliver vaccines – supported by goodwill and excitement to be hastening the end of the pandemic. As the vaccine programme progresses, our exit from lockdown means demand for non-COVID health care will increase. This, together with the need for booster vaccines (due to new strains or declining immunity), may mean this balancing act becomes more challenging.

The Health Foundation’s COVID-19 impact inquiry, reporting in summer 2021, is exploring the disproportionate impacts of the pandemic on different groups and geographies, and the implications for health and health inequalities. Vaccination, done equitably, is one way of protecting those groups hardest hit from further harm, and this analysis will contribute to the work of the inquiry.