Mandatory SARS-CoV-2 vaccination for NHS workers in England

By annoymous.

Subsequent to our writing of this blog entry for publication, the UK government announced it was reconsidering its decision to enforce an NHS England vaccine mandate. Steps are already underway to formalise this decision in parliament as we speak, but this suggests the mandate is unlikely to progress any further. We note that the vaccine mandate has already been enforced for three months in social care settings and has led to staff shortages (approximately 40,000 new vacancies now exist in that setting as a result) and that due to this change in direction there is likely to be some confusion surrounding this in our profession and amongst the public. For these reasons, we have decided to continue to publish this entry to explain why a COVID vaccine mandate may be an ineffective strategy in health and social care settings and what may be more helpful instead to help staff navigate vaccine hesitancy in the context of the ongoing pandemic. [Update added on 02.02.2022] 

We are a group of psychology professionals working in an acute NHS Trust in England. Core to our role is to seek to understand and empathise, and to challenge stigma, racism and discrimination wherever we encounter it. We write to raise the issue of the impact of mandated COVID vaccines upon staff working within the health and social care systems of the NHS in England. 

Supporting, promoting and encouraging uptake of the vaccination programme for healthcare staff to protect themselves, patients and colleagues is important; however there should remain some choice in this decision. 

There is a wider socio-political context to vaccine hesitancy which has not been acknowledged by our professional bodies, government, or most of the media. The mandating of Covid vaccines for NHS workers in England is a highly political act and will disproportionally affect People of the Global Majority*. 

We write this statement to oppose the mandatory vaccination of NHS workers. 

In doing so, we aim to promote understanding of and to stand in solidarity with our colleagues who have declined the vaccine and now face losing their careers. We call on our elected representatives in government and on our professional bodies to take a stand against yet another example of structural racism.

Several studies have examined reasons for SARS-CoV-2 vaccine hesitancy in People of the Global Majority. To summarise, these include:

1. Lack of trust in institutions (such as the government and employers)
2. A history of unethical research in People of the Global Majority
3. Under-representation of People of the Global Majority in vaccine studies
4. Previous negative and discriminatory experiences in healthcare
5. Confusing and conflicting information. For example, participants in one study cited changing guidance, overwhelming amounts of information and poor provision of information in languages other than English. 

These influences intersect with other factors, including socio-economic status and access to resources. More broadly, People of the Global Majority have a collective history of lack of autonomy over their own bodies and of their bodies being abused by people in power. 

For all these reasons, it is entirely understandable that rates of vaccine acceptance are lower in People of the Global Majority (at the same time it should be noted that there is heterogeneity across groups).

Almost a year ago the Organisation for Economic Co-operation and Development (OECD) published guidance about how governments can enhance public trust in Covid-19 vaccination.  This includes: 

• communicating clearly
• engaging and working with communities when developing their vaccine strategies
• fostering trust in institutions by treating citizens consistently and fairly; demonstrating the values of integrity, community engagement and fairness are seen to be key in engendering trust.  

Social cohesion is undermined when citizens feel unfairly treated, and makes it less likely that people will “co-operate” [their words]; thus it seems reasonable to infer that the introduction of a vaccine mandate in one sector (NHS and social care staff in England) that discriminates against People of the Global Majority is likely to impact negatively on the trust the wider community has in government, and make it less likely that some of this community will consider vaccination themselves. 

Indeed, an unpublished survey by researchers at the London School of Economics and Political Science found that policies such as mandatory vaccination would, in some people, fuel distrust and further reduce the likelihood of them accepting the vaccine3. 

Dr Hans Kluge, the Europe Director of the World Health Organisation recently stated that mandating vaccines should only be used as “an absolute last resort”, stressing the importance of engaging with the community first.

Instead of demonstrating any understanding of factors that influence decision-making and behaviour, politicians and the media simply talk about the burden on hospitals caused by “selfish” unvaccinated people, and about “anti-vaxxers”. Such talk from influential sources risks exacerbating stigma and overt racism towards People of the Global Majority. 

The impact of mandatory vaccination on individuals and the NHS in England will be great. For individuals who decline the vaccine, the impact of a loss of career cannot be overstated. For an already-stretched NHS with many thousands of unfilled vacancies, the impact on patient care of fewer staff will be significant and cause reductions in services. This will disproportionately, once again, affect People of the Global Majority and will widen existing health inequalities. 

An NHS that has shown itself to be hostile towards People of the Global Majority through the implementation of this mandate will face even great difficulty recruiting in future. Service users will, understandably, be even more likely to regard healthcare services as untrustworthy and racist.

These effects will be exacerbated by the speed at which the policy is being implemented at a time of intense pressure on the NHS. Many NHS managers and colleagues in England are describing the distress they feel in having to implement this policy and under such a tight deadline when they are already experiencing heightened levels of stress and pressure. ​

What’s the alternative to mandatory vaccination?

As outlined in the recent guidance from the British Psychological Society (BPS)5, the COM-B model of behaviour is drawn upon to outline the positive influences that may increase vaccine uptake among the population. In addition, six key principles are highlighted to optimise messaging, access and uptake of the vaccination. 

Trust is a key principle here and one that may be more helpfully adopted if there were to be an extension of the timeframes for the mandated vaccine. Trusted members of a community and wider staff support are essential to dispel misinformation, whilst also decreasing potential stigma of ambivalence or reluctance to get vaccinated. 

We are also aware that some of our colleagues and other appropriately trained professionals are helping individuals and groups in the NHS who are ambivalent about vaccination to work through this in a way that respects their individual autonomy. This support work has increased in the last few months. 

However, these interventions take time and working with trusted community members in marginalised communities is important and helpful to address widening health inequalities that are likely to emerge due to this vaccine mandate.

Time is needed to ensure that the communication channels and messengers are appropriate, and to prevent a close-down on the discussion and decision-making process, within the NHS workforce and beyond.

*Please note: We use the term People of the Global Majority throughout this article as it is more factually accurate than Black, Asian and Minority Ethnic people. Minoritised ethnic and racial groups make up the majority of the global population (approximately 87-90% according to 2019 UN report estimates: https://population.un.org/wpp/Publications/Files/WPP2019_Highlights.pdf) and the former term also allows self-definition independent of white supremacist hierarchies of race and ethnicity

References

1. Razai MS, Osama T., McKechnie DGJ & Majeed A. (2021). Covid-19 vaccine hesitancy among ethnic minority groups. BMJ; 372:n513.
2. Woolf K, McManus IC, Martin CA et al. (2021). Ethnic differences in SARS-CoV-2 vaccine hesitancy in United Kingdom healthcare workers: Results from the UK-REACH prospective nationwide cohort study. The Lancet Regional Health – Europe, 9, 100180.
3. Unpublished blog reporting on a survey by the London School of Economics: Asaria M, Costa-Font J & Akaichi F. (2021). Why some ethnic groups are more likely to refuse the COVID vaccine (and what we could do about it). https://blogs.lse.ac.uk/covid19/2021/10/21/why-some-ethnic-groups-are-more-likely-to-refuse-the-covid-vaccine-and-what-we-could-do-about-it/
4. The Organisation for Economic Co-operation and Development (OECD). (2021). Enhancing public trust in Covid-19 vaccination: the role of governments. https://www.oecd.org/coronavirus/policy-responses/enhancing-public-trust-in-covid-19-vaccination-the-role-of-governments-eae0ec5a/ 
5. British Psychological Society (2021). Optimising vaccination uptake for Covid-19 – Guidance. https://www.bps.org.uk/sites/www.bps.org.uk/files/Policy/Policy%20-%20Files/Optimising%20vaccine%20uptake.pdf 
6. Michie S, van Stralen MM & West, R. (2011). The Behaviour Change Wheel: A new method for characterizing and designing behaviour change interventions. Implementation Science, 6(42). doi:10.1186/1748-5908-6-42.
7. Michie S, Atkins L & West R. (2014). The Behaviour Change Wheel: A guide to designing interventions. London: Silverback Publishing.