© National Audit Office 2022

The rollout of the COVID-19 vaccination programme in England

Department of Health & Social Care and
Department for Business, Energy & Industrial Strategy

REPORT

by the Comptroller
and Auditor General

Session 2021-22
25 February 2022
HC 1106

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The rollout of the COVID-19 vaccination programme in England

Department of Health & Social Care and
Department for Business, Energy & Industrial Strategy

Report by the Comptroller and Auditor General

Ordered by the House of Commons
to be printed on 23 February 2022

This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act

Gareth Davies
Comptroller and Auditor General
National Audit Office

21 February 2022

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The National Audit Office study team consisted of:

Charlie Barbato, Jonathan Hyde, Francis Lind, David Liu, Marianne O’Neill, Natalie Low, Kirsty Rhodes and David Xu, under the direction of Tim Phillips.

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Key facts

Summary

Introduction

1 COVID-19 vaccines first became available at the end of 2020. Since then, vaccination has been central to the government’s pandemic response. The UK Health Security Agency (UKHSA) estimated that by the end of September 2021, vaccinations may have averted as many as 128,000 deaths and 262,000 hospitalisations by September 2021.

2 A number of national and local bodies have been involved in the COVID-19 vaccine programme (the programme) as follows:

The Vaccine Taskforce (the Taskforce), created in April 2020, one of whose objectives is to secure vaccine supplies for the UK.

Initially, the Taskforce delivered its responsibilities on behalf of the Department for Business, Energy & Industrial Strategy (BEIS). From August 2021, the Department of Health & Social Care (DHSC) assumed accountability for Taskforce activities relating to procurement, clinical testing and development. DHSC is also responsible for planning how to administer the vaccine to the public in England.

NHS England and NHS Improvement (NHSE&I) leads on operational delivery of COVID-19 vaccinations in England. It has worked with Public Health England (PHE) on vaccine supply, storage and distribution within England. From October 2021, PHE’s responsibilities transferred to the new UKHSA.

A range of local healthcare providers – NHS hospitals, GPs and community pharmacies – have administered vaccines in their own premises and other settings including dedicated vaccination centres.

3 In implementing the programme, the government has followed advice from the Joint Committee on Vaccination and Immunisation (JCVI) and the Chief Medical Officers. This advice determines who is eligible and should be prioritised for vaccination, and which vaccines can be given to which groups. As further evidence on the safety and effectiveness of the COVID-19 vaccines became available and the nature of the COVID-19 pandemic has changed over time, advice has continued to change and has often had to be implemented at extremely short notice. As with other vaccines, the Medicines and Healthcare products Regulatory Agency (MHRA) has to approve COVID-19 vaccines before they can be used and monitors safety after approval.

Scope of this report

4 In December 2020, we published our Investigation into preparations for potential COVID-19 vaccines. At the time, the Taskforce had signed five contracts with vaccine suppliers and one vaccine had been approved for use. This report extends our examination up to the end of October 2021, by which time four vaccines had been approved for use and the rollout of first and second doses of COVID-19 vaccinations to adults had taken place. The programme had also commenced rollout of first doses to 12- to 17-year-olds, and booster vaccinations. Since October 2021, the programme has expanded further, including the broadening and acceleration of the booster programme and second doses for 12- to 17-year-olds.

5 This report evaluates the government’s COVID-19 vaccine programme focusing on events up to the end of October 2021 and assessing whether the programme is well placed to meet its objectives in full. The report focuses on England, with the exception of procurement which the government has done on a UK-wide basis. We describe aspects of clinical advice, vaccine certification, the booster programme and some events after October 2021 but do not evaluate them in depth.

Key findings

The rollout of vaccinations to the public

6 The vaccine programme met stretching and unprecedented targets to offer two doses of COVID-19 vaccine to most adults in a short space of time. The government made public commitments to offer vaccines first to priority groups and then to the entire adult population of England. Up to July 2021, NHSE&I achieved all its major deployment targets, including offering a first vaccine dose to nine priority groups by 15 April and extending that offer to all adults by 19 July. The programme met its target to vaccinate two-thirds of all adults by 19 July. By the end of October, it had administered around 87 million doses, about six times the number in the previous annual flu vaccine programme (paragraphs 3.6 and 3.7).

7 Uptake has exceeded expectations and has been higher than for previous flu vaccination programmes. As the rollout began, Office for National Statistics surveys suggested that the large majority of people (84%) felt positively about being vaccinated. This figure had increased to 96% by June/July 2021. Vaccine uptake has exceeded NHSE&I’s initial planning assumption that 75% of adults would take two doses. By the end of October 2021, 85% of adults had received two doses. Uptake of flu vaccines in the winter of 2019-20 in England was 72% for people aged 65 and over and 45% for people under 65 in a clinical risk group. Uptake in England also compared well with the other home nations and European Union countries: 85% received two doses compared with a range of 76% to 93% (paragraphs 3.5, 3.22 and 3.28).

8 Despite national and local efforts to address inequalities, lower vaccination rates persist in some groups. Uptake of COVID-19 vaccinations at the end of October 2021 remained substantially below the national average for:

younger age groups, being lowest among those aged 18–24 (64%)
and 25–29 (68%);

particular ethnic minority groups, being lowest among adults of Chinese origin (48%), Black Caribbean origin (49%) and Black Other origin (49%), compared with 76% for all ethnic origins (this analysis does not adjust for age and uses a slightly different measure of uptake from the 85% referred to above); and

expectant mothers (in October 2021, 29% of women giving birth had received at least two doses of COVID-19 vaccine).

Previous vaccination programmes have shown that uptake varies for different groups and in complex ways. The COVID-19 vaccine programme recognised the need for a range of approaches to address low uptake, including campaigns to increase confidence in vaccine safety, targeted materials for different communities, different routes to get vaccinated, and partnerships with community organisations. There are signs that some measures succeeded in improving uptake but the government has not yet identified how it can fully overcome persistent inequalities (paragraphs 3.22, 3.25 to 3.28 and Figure 22).

9 The programme has not met some later objectives, including one to vaccinate most 12- to 15-year-olds by late October 2021. The government decided to extend vaccination eligibility to 12- to 15-year-olds in the middle of September and originally planned to provide vaccines primarily through school-based immunisation services. However, there were a number of challenges to this rollout and by the end of October only 25% of the age group had been vaccinated. NHSE&I later broadened its offer to enable 12- to 15-year-olds to receive vaccines at other sites. By the end of January 2022, 58% had been vaccinated with one dose (paragraphs 3.7 and 3.8).

10 Overall, the programme has taken steps to make the vaccine convenient to access; GPs and community pharmacies have administered many more doses than originally planned. NHSE&I set up three main routes to access vaccines: GPs and community pharmacies (which it assumed would provide 56% of vaccinations); vaccination centres (which it assumed would provide 41%) and hospitals (for the remaining 3%). By the end of October, 71% of vaccines had been administered by GPs and community pharmacies, through a variety of local services and locations, and only 21% had been delivered at vaccination centres. In terms of delivery costs, dedicated vaccination centres have been the most expensive method at £34 per dose compared with £24 for GPs and community pharmacies. GPs and community pharmacies were the most popular delivery model for all priority groups although people aged under 65 were more likely than others to use dedicated vaccination centres (paragraphs 3.9 to 3.11).

11 A combination of existing staff, returning healthcare staff, newly trained vaccinators and volunteers have administered the vaccines. DHSC and NHSE&I anticipated that at its peak the programme would need 60,000 vaccinators and 65,000 non-clinical staff. They increased capacity by legislating to allow a wider range of individuals to give vaccinations and by recruiting clinical and non-clinical paid staff and volunteers. In our local case study interviews, we heard about the goodwill, flexibility and dedication needed to set up and run vaccination sites at such pace and scale. Staff accepted that the programme faced inherent uncertainties but there was frustration that important changes, for instance offering vaccines to 12- to 15-year-olds outside school, were sometimes announced in the media before NHSE&I had communicated them to local sites. NHSE&I told us that it was unable to communicate in advance with local sites owing to the confidential nature of the advice (paragraphs 3.13 and 3.17).

12 NHSE&I and NHS Digital (NHSD) created new digital tools to support the vaccine deployment, making effective use of imperfect existing data. The programme set up a national data system that allowed the NHS to identify, record and transmit patient vaccination data across the health and care system. NHSE&I also created central dashboards with detailed and real-time analysis of uptake and supply. These tools supported programme leaders to manage key programme risks and monitor divergence from central directions in local areas. Some priority groups (for example, the social care workforce and unpaid carers) were hard to identify from the main GP records but NHSE&I made creative use of multiple other data sources to improve identification. NHSE&I, working with NHSD, set up the national online booking system, which was primarily available for dedicated vaccination centres and community pharmacies. Our local case study areas had mixed views on how well this had facilitated access and supported their operations (paragraphs 3.18 to 3.21, 3.23 and 3.24).

Update on overall costs, procurement and supply

13 Up to the end of October 2021, the programme had spent £5.6 billion out of total available funding of £8.3 billion for the two years to the end of March 2022.

The £8.3 billon funding consists of £4.6 billion for the Taskforce, primarily to purchase vaccines, and £3.7 billion for vaccine deployment.

The £5.6 billion expenditure comprises £3.3 billion by the Taskforce, of which £2.9 billion was to purchase vaccines, and £2.2 billion for vaccine deployment.

Based on all UK agreements in place as at the end of October with six suppliers, we calculated that the average procurement cost per dose was £15.02 (including VAT), although this has varied between suppliers and over time as the market situation has changed.

For the period up to the end of October, we calculated that the average deployment cost per dose administered was £25.70. (Due to the different types of doses covered, this cannot be added together with the average procurement cost above to produce an average total cost, and there are additional deployment costs, for example, the use of volunteers, that cannot be easily quantified.) (paragraphs 1.5 to 1.8).

14 By the end of October 2021, the Taskforce had contracts or agreements in place with six suppliers for more than 340 million doses of vaccine to be delivered to the UK by the end of 2022. This compares with around 357 million doses contracted for or agreed in principle at the time of our last report in December 2020. Up to the end of October 2021, 145.9 million doses had been supplied against the UK vaccine contracts, and the Taskforce had paid out £2.8 billion on vaccine procurement contracts. Including future commitments, total contract costs have increased from £3.7 billion to £5.8 billion. This implies a substantial increase in the procurement cost per dose. This reflects the fact that there is a larger share of the more expensive vaccines now approved for use in the October 2021 portfolio. The supply contracted for may ultimately exceed the UK’s vaccination needs but this depends on how the pandemic and government policy evolve. To date, the Taskforce has used various methods to optimise national supply and reduce surpluses, including cancelling or rescheduling deliveries, international donations, and bilateral transfers with other countries (paragraphs 2.6, 2.7, 2.9, 2.10 and 2.19).

15 Up to the end of October 2021, there was an estimated total wastage of around 4.7 million doses, or 4.0% of total supply, in the vaccine programme in England; this included 1.9 million doses unused after changes to clinical advice about the AstraZeneca vaccine. Wastage can occur when vaccine is not handled in line with guidance (for instance, regarding refrigeration) or cannot be used before its expiry date. We estimated overall wastage for England at 4.0% of total supply, lower than the 15%–20% that the vaccine programme initially assumed: under 1% across the national distribution and storage chain and 4.5% locally. There was a particular challenge with expiring AstraZeneca doses after JCVI’s recommendation that people under 40 should preferably not be offered it. Although the Taskforce, working with PHE and others, was able to avoid some wastage by redirecting 4.5 million AstraZeneca doses to other countries, vaccines already at local sites had to be destroyed in line with regulations. Approximately 1.9 million doses were written off. Local providers were allowed to transfer stock between one another: our local case study interviews highlighted the value of this, although three felt the process was too slow and bureaucratic (paragraphs 2.17 to 2.19).

Success factors and future risks

16 The COVID-19 vaccine rollout was the biggest vaccination programme in UK history. Those delivering it employed a number of successful approaches to achieve most of its objectives up to October 2021. In particular, we have noted the following that facilitated delivery at speed:

Early and decisive action with a clear statement of the risks involved in different possible approaches.

A conscious decision to pursue more than one solution, both in terms of vaccines and vaccination sites to provide flexibility and contingency.

The adapting of existing processes to streamline vaccine development, procurement, approval and authorisation.

Great clarity of purpose and priorities from the start of the vaccination rollout.

A balance between central command-and-control and wider empowerment (particularly once it was acknowledged that GPs and pharmacies would play a bigger role than originally planned).

Using existing infrastructure and expertise where possible, and identifying early on where new infrastructure was needed.

The effective use of data to manage the programme closely and intervene quickly when problems emerged (paragraphs 1.16 to 1.17, 2.20 and 3.29 to 3.30).

17 There are considerable risks to the programme’s continuing success.

In the autumn of 2021, the programme expanded to include booster doses, first for some and then for all adults, and second doses for 12- to 17-year-olds. Following the emergence of the Omicron variant in winter 2021, new targets were set to offer all adults a booster by the end of December. These developments have meant the programme continuing to operate at a very high scale and pace and with significant complexity into a second year.

There are still around 3.7 million unvaccinated adults who are unevenly spread throughout the population.

Our assessment is that staffing remains a major risk, due to staff burnout, and the lack of surplus capacity in the healthcare system generally.

In November 2021, the Taskforce signed contracts for 114 million more vaccine doses to be delivered in 2022 and 2023. This will provide flexibility to meet increases in demand and acquire new variants of vaccines, but the programme will have to manage carefully any resulting surpluses and the increased risk of wastage (paragraphs 2.7, 2.21 and 3.31 to 3.33).

18 Up to the end of 2021, DHSC, BEIS and other national bodies had not yet identified what a sustainable long-term model of regular COVID-19 vaccination would entail. Given the continuing significant uncertainties of the pandemic, at the end of 2021 DHSC still felt that it was too early to fix on a business-as-usual approach to COVID-19 vaccination but told us it was planning to address this in 2022. UKHSA noted that the emergency arrangements may not be best for long-term efficient working. In good time, DHSC and BEIS will need to consider the best long-term organisational structure for the new roles currently performed by the Taskforce and NHSE&I, alongside UKHSA’s existing responsibilities, and how future costs and other resources may need to differ from the emergency response (paragraphs 1.18, 2.21 and 3.31).

Conclusion on value for money

19 Initiated in 2020, the vaccine programme has operated at unprecedented pace, scale and complexity, and in conditions of profound uncertainty, to achieve the pressing objectives of supporting the creation of vaccines, securing access to them, and administering them to the population as quickly as possible. It is through the collective efforts of many national and local public bodies, scientists, vaccine manufacturers, and individual staff and volunteers, as well as government’s power as a coordinator and funder, that so many of the programme’s objectives have been met and in some areas exceeded.

20 In our review, we saw many examples of good practice, including clarity of purpose and priorities, timely and data-driven decision-making, and a willingness to innovate and adapt where necessary balanced with the repurposing of existing infrastructure and expertise. National and local partners showed an ability to adapt quickly, for example the rapid shift to deliver more vaccinations through GPs and pharmacies. The evidence indicates that the programme has saved lives and reduced the incidence of serious illness and hospitalisation.

21 Given the unprecedented circumstances of the pandemic and the programme’s achievements up to October 2021, we assess that it has provided value for money to date. By the end of October, the programme had spent £5.6 billion to achieve its objectives. Much about COVID-19, the vaccines market and the UK’s future requirements remains unpredictable but far more is now known than in 2020. The programme needs to identify a clear path to a future sustainable model, securing the benefits of its many innovations and ensuring it has a full picture of costs and workforce requirements as it takes key decisions. It needs to challenge anew all elements of its cost base and adapt accordingly. Most importantly, it needs to maintain the high levels of vaccine uptake it has achieved among the general population and increase levels for groups where uptake still lags behind.

Recommendations

22 Our recommendations are as follows:

a In the light of the expanded and accelerated booster programme, NHSE&I should take additional steps to manage the vaccine workforce and its welfare sustainably, and to examine how the programme can minimise its potential adverse impact on other health and public health services, bearing in mind it is the same workforce which delivers all these services. It should also ensure it gives front-line providers the necessary lead-in time to prepare for programme changes.

b NHSE&I and UKHSA, working with local and national partners, should seek new ways to increase uptake for groups where rates are lower than for the rest of the population, and should also evaluate what has worked well to date and could be replicated in future in other vaccination and similar public health programmes.

c The Taskforce, NHSE&I and UKHSA, working with local partners, should set out a clear strategy for managing surpluses and wastage in 2022 and review the overall expected wastage, ensuring they learn lessons from the write-offs required for AstraZeneca.

d Taking into account its ongoing procurements, the Taskforce should set out a clear strategy for how it will maintain flexibility to respond to the continuing uncertainties of the pandemic, including the emergence of new variants, and changes in demand. This should include consideration of the mix of vaccines in its portfolio, timing of deliveries and the relative cost and efficacy of different vaccines.

e DHSC and BEIS, working with the Taskforce, NHSE&I and UKHSA, should capture wider lessons from the programme, and identify what adaptations and innovations they should retain for other health and public health programmes and future responses to emergencies. By the same token they should take steps to identify and address acknowledged weaknesses, such as the accuracy and availability of care sector data and the identification of unpaid carers.

f DHSC and BEIS, working with the Taskforce, NHSE&I and UKHSA, should set out a clear plan to identify and reach a sustainable future model for COVID-19 vaccination, clearly setting out responsibilities at national and local level, based on a considered review of the costs, structures, staffing and delivery models used so far. In advance of any formal plan, they should seek early opportunities to consolidate COVID-19 vaccine activities within existing structures.

Part One

The COVID-19 vaccine programme

1.1 Effective COVID-19 vaccines first became available at the end of 2020. Since then, vaccination has been central to the government’s pandemic response.1 The rollout was the biggest and most complex vaccination programme in UK history. Our first report on the vaccine programme, Investigation into preparations for potential COVID-19 vaccines,2 considered events up to December 2020. At that stage, we reported how the programme had to work at pace and without any certainty that an effective vaccine would be found. This report looks in detail at what happened between then and the end of October 2021.

1.2 This part provides an overview of the COVID-19 vaccination programme,3 including:

roles and responsibilities;

funding and costs to date; and

benefits and impacts.

Part Two then examines progress with COVID-19 vaccine procurement and supply. Part Three looks in detail at the rollout of COVID-19 vaccines to the public.

Roles and responsibilities

1.3 A number of national and local bodies have been responsible for procuring, supplying and administering COVID-19 vaccines (Figure 1):

Created in April 2020, the Vaccine Taskforce (the Taskforce) has been responsible for procuring COVID-19 vaccines from pharmaceutical companies, supporting vaccine research and developing future manufacturing capacity in the UK.

Initially, the Taskforce delivered its responsibilities on behalf of the Department for Business, Energy & Industrial Strategy (BEIS). From August 2021, the Department of Health & Social Care (DHSC) assumed accountability for Taskforce activities relating to procurement and clinical testing. DHSC is also responsible for planning how to administer the vaccine to the public in England.

NHS England and NHS Improvement (NHSE&I) leads on operational delivery of COVID-19 vaccinations in England, including designing and implementing delivery models. NHSE&I worked with Public Health England (PHE) on vaccine supply, storage and distribution within England. From October 2021, PHE’s responsibilities transferred to the new UK Health Security Agency (UKHSA).4

A range of local healthcare providers – NHS hospitals, GPs and community pharmacies – working with their integrated care systems, have administered vaccines in their own premises or other settings, including temporary vaccination sites such as dedicated vaccination centres, in people’s homes and in care homes.5

Numerous commercial and third-sector bodies hold contracts to support the programme, including to manufacture, transport and store vaccines, and to provide venues and volunteers.

1.4 In addition to the Chief Medical Officer for England, the government’s most senior advisor on health matters, two bodies have important roles in providing independent clinical advice and monitoring:

The Medicines and Healthcare products Regulatory Agency (MHRA) is the UK regulator, which approves vaccines for use and monitors safety after approval.

The Joint Committee on Vaccination and Immunisation (JCVI) advises the UK government on who is eligible for vaccination and how to prioritise them.

Funding and costs

1.5 The total funding available to the COVID-19 vaccine programme in 2020-21 and 2021-22 is £8.3 billion (Figure 2). This comprises:

£4.6 billion for the Taskforce, of which the majority, £3.9 billion, was to purchase vaccines; and

£3.7 billion to support deployment in England, including the rollout of two vaccinations and boosters to all adults, and two doses to all 12- to 17-year-olds.

1.6 The programme’s actual expenditure has been subject to many uncertainties, including the unit costs of vaccines purchased, the eligible population and the level of uptake, delivery models, and the number of doses required per person. Up to the end of October 2021, the programme had spent a total of £5.6 billion (Figure 2):

The Taskforce spent £3.3 billion, including £2.9 billion on purchasing COVID-19 vaccines and £0.2 billion on efforts to increase domestic manufacturing capacity.

Up to the end of October, COVID-19 vaccine deployment had cost £2.2 billion. Of this, £1.6 billion was directly related to work at vaccination sites, including around £1.1 billion for services provided by GPs and community pharmacies, £0.4 billion for vaccination centres, and £0.1 billion for NHS hospitals.

1.7 We calculated that the average procurement cost per dose was £15.02 (including VAT), based on all agreements in place in October 2021 (including vaccines not approved or used in the UK).6 The average procurement cost per dose varies considerably between suppliers and for the same supplier over time as market circumstances and contractual terms changed. The average procurement cost per dose, based only on the contracts for the three vaccines actually deployed in the UK, is higher than £15.02. We have not presented these data in the report in order to protect the government’s commercial position. For the period up to the end of October, the average cost of administering each dose was £25.70.7 (The two averages cannot be added together to get a total cost per dose as the first is based on doses contracted for by the end of October 2021, while the second is based on doses administered up to the end of October 2021.)

1.8 Additionally, some programme costs cannot be easily quantified. Stakeholder groups and officials in local case study areas told us that the programme’s success relied on goodwill, flexibility and support from many healthcare staff and volunteers. Organisations often provided venues for free or at reduced rates, meaning that some costs might be higher were the vaccination programme to continue in future. Given the unusual circumstances of the pandemic and the terms on which developers have been willing to supply COVID-19 vaccines, government has also provided broad indemnities to the producers of approved vaccines, as noted in our December 2020 report. This gives uncapped cover for future claims against producers for adverse effects of their vaccines. A number of existing clinical negligence and insurance schemes provide indemnity cover to GPs, pharmacies and NHS trusts for future claims for adverse events occurring during the administering of COVID-19 vaccines.

1.9 In the Spending Review 2021, DHSC received £9.6 billion for all its key COVID-19 programmes. At the time of reporting, it told us it was still in discussions with Her Majesty Treasury on how this would be allocated between programmes. As part of the BEIS Spending Review settlement, the Taskforce received £429.5 million for developing UK manufacturing capacity for the period 2022-23 through to 2024-25.

Programme impacts

1.10 A key impact of the vaccine programme relates to the speed with which it has operated. The UK government identified that a successful vaccination programme could protect people from serious illness and death and help them return to a more normal life. The government also recognised that these benefits could be maximised through faster vaccine deployment. It took early action to develop a portfolio of possible vaccines and to sign contracts with their manufacturers before regulatory approval to use them had been granted. In December 2020, it became the first country in the world both to authorise a COVID-19 vaccine and to begin vaccination (Figure 3).

1.11 In rolling out vaccines to the public the programme initially had three overarching objectives:

a first, to vaccinate the entire adult population as soon as practicable;

b second, to prevent further serious illness and death from COVID-19; and

c third, to help restore and protect the UK’s economic growth.

1.12 Against the first objective, the programme met all of its early deadlines to offer vaccines to the public. A large majority of people, but still not the entire population, has been vaccinated. This is covered in detail in Part Three (see paragraphs 3.5 to 3.8).

1.13 Against the second objective, clinical trials for all UK-approved vaccines showed that they reduced the risk of developing symptomatic COVID-19 infections and becoming seriously ill.8 PHE and UKHSA have subsequently monitored real-world data on the vaccines’ effects.9 Based on emerging evidence, in November 2021, UKHSA assessed that COVID-19 vaccination reduced an individual’s risk of hospitalisation by 90%–99%, and death by 90%–99%. Assuming no other physical interventions (for example, social distancing), UKHSA estimated that the programme could have prevented 128,000 deaths and 262,000 hospitalisations by 24 September and 19 September respectively. Across the country, levels of hospitalisation and mortality at the end of October 2021 were significantly lower than during previous periods with similar levels of infection (Figure 4).

1.14 The impact of vaccines on overall transmission of the virus has been weaker than on serious infection and death. Despite a high level of vaccine uptake, the number of infections also remained high between August and October 2021. The Office for National Statistics (ONS) reported that full vaccination with Pfizer or AstraZeneca was up to 73% and 62% effective against infection with the Delta variant but that the effects did wane with time.

1.15 Against the third objective, the high level of vaccine uptake was vital to the government’s decision progressively to remove many restrictions on society and the economy in the period up to July 2021. The ONS said the economy in England grew by 0.4% in August during the first full month without COVID-19 controls. In the Taskforce’s business case for the booster programme, it estimated the economic benefits could be between £47.6 billion and £168 billion. In our view, it is unlikely to be possible to quantify the economic impact of the vaccine programme in isolation because of the number of other factors in play. Nevertheless, greater or longer restrictions on everyday life, including on economic activity, could have been necessary without vaccinations.

Success factors and future risks

1.16 It usually takes several years to develop a vaccine, approve it for use and roll it out to the public. For COVID-19 vaccines, eight months elapsed between setting up the Taskforce and starting to administer vaccines to the population. Ten months after that, 85% of people aged 18 and over in England had received two doses of a COVID-19 vaccine. To deliver at such pace, government bodies and others worked in different ways.10 As shown in Figure 5 the timing of contract negotiations, clinical trials and regulatory approval were significantly adapted for COVID-19 vaccines, with many more activities carried out in parallel than would usually be the case. Together with PHE, the Taskforce and NHSE&I took on responsibility for the procurement, contract management and distribution of COVID-19 vaccines. Prior to COVID-19, PHE had lead responsibility for many of the national vaccination and immunisation programmes.11

1.17 Our 2021 report Lessons learned: Delivering programmes at speed identified important considerations for programmes seeking to achieve their objectives at pace (Figure 6).12 We have found that many of these were relevant to the vaccine programme and we provide more details of this in Parts Two and Three.

1.18 The Taskforce and the COVID-19 vaccine deployment programme represent a substantial part of the government’s emergency COVID-19 response. In December 2021, a combined total of more than 700 staff (full time equivalent) in DHSC, NHSE&I and the Taskforce worked on COVID-19 vaccination, compared with around 20 staff employed on matters related to vaccinations within PHE, DHSC and NHSE&I prior to the pandemic. DHSC told us in November 2021 that it was starting to consider, together with BEIS and other national bodies, what a future model for COVID-19 vaccination would entail but that it was too soon to be certain about this owing to the ongoing pandemic response. DHSC said it planned to make decisions about this in 2022. UKHSA noted that the current emergency arrangements may not be best for long-term efficient working. In Parts Two and Three, we set out some of the main future risks that national bodies will have to manage if the COVID-19 vaccination programme becomes a regular feature of the health landscape.

1 In its 2021 Autumn and Winter Plan, the government stated that “the main line of defence [against COVID-19] is now vaccination rather than lockdown”.

2 Comptroller and Auditor General, Investigation into preparations for potential COVID-19 vaccines, Session 2019–2021, HC 171, National Audit Office, December 2020.

3 As set out in our December 2020 report, vaccines will be bought for the UK, Crown Dependencies and Overseas Territories. Northern Ireland, Scotland, Wales, Crown Dependencies and Overseas Territories are each responsible for deploying the vaccine to their own populations. This report focuses on deployment in England, while examining procurement on a UK-wide basis.

4 PHE was formally abolished in October 2021, and responsibilities relating to the COVID-19 vaccine programme were taken over by the new body UKHSA. Where we describe activities taking place up to the end of October, we will mainly refer to PHE.

5 Integrated care systems (ICSs) are new partnerships between the organisations that meet health and care needs across an area, such as hospitals and social care providers, to coordinate services and to plan in a way that improves population health and reduces inequalities between different groups.

6 The calculation is based on all doses contracted for by the end of October 2021, whether or not the vaccine was approved or deployed. This includes vaccines with non-binding agreements in place, but excludes the terminated Valneva contract. Exchange rates used are as at the end of October 2021 as the Taskforce does not hedge its foreign exchange exposure. See paragraph 2.7 for further analyses of procurement cost per dose.

7 The calculation is based on the total costs of the deployment programme, divided by the number of first, second, third and booster doses administered up to the end of October 2021. The calculation includes distribution, storage and transportation costs incurred on doses which have not yet been administered or have expired.

8 It is important to measure both vaccine efficacy (how well a vaccine performs in clinical trials) and vaccine effectiveness (how well a vaccine works in the real world). Vaccine efficacy will determine whether or not a vaccine gets approved for use by regulators, while effectiveness must be monitored following approval and deployment.

9 The Taskforce has also funded studies on the real-world effectiveness of vaccines, for example “CovBoost”, which examined which COVID-19 vaccines were most effective as a booster vaccination.

10 Our December 2020 investigation documented that government had organised itself to work at pace through: the establishment of the Vaccine Taskforce; changes to BEIS, HM Treasury and Cabinet Office approval procedures; the formation of a Ministerial Panel (including BEIS, DHSC, the Treasury and Cabinet Office) to fast-track approval of vaccine purchases; and the creation of a single deployment programme led by NHSE&I.

11 This reflects PHE’s prior responsibilities for childhood vaccines. For adult influenza, GPs and pharmacies are responsible for buying their own vaccines. From October 2021, UKHSA took on PHE’s vaccine-related responsibilities, both for COVID-19 and other vaccines.

12 Comptroller and Auditor General, Lessons learned: Delivering programmes at speed, Session 2019-2021, HC 667, National Audit Office, September 2021.

Part Two

Vaccine procurement and supply

2.1 This part of the report looks at vaccine procurement and supply, including:

the overall approach used and progress to date; and

success factors and future risks for procurement and supply.

2.2 For COVID-19, the Vaccine Taskforce (the Taskforce) was responsible for procurement, the subsequent management of contracts and incoming supply. Public Health England (PHE) and NHS England and NHS Improvement (NHSE&I) have run the distribution process for England.

Overall procurement strategy

2.3 One of the Taskforce’s initial objectives was to secure access to promising COVID-19 vaccines for the UK population as quickly as possible.13 Its strategy was to build a broad portfolio, recognising that many vaccines were still in development and could fail to receive regulatory approval.14 This approach is examined in detail in our first report.

2.4 After March 2021, the Taskforce adapted its approach to include buying vaccines for adult booster vaccinations and for young people, and against new virus variants when available. In new contracts and contract amendments between December 2020 and the end of October 2021 (for supply up to the end of 2022), the Taskforce sought where possible to retain flexibility of supply by including options to terminate contracts and increase doses. To maintain the programme’s effectiveness against future virus variants, it also included options to substitute or procure vaccine variants or reformulations.

2.5 The Taskforce has now begun procuring vaccines for 2023. It plans to continue with its ‘managed risk’ strategy of buying different types of vaccine and from a range of manufacturers. Over time it wants to achieve a closer alignment between what it purchases and likely demand, but continuing uncertainties during the pandemic mean that has not been possible to date.

Update on procurement and supply

2.6 In December 2020, we reported that the Taskforce had seven agreements in place with seven suppliers for 357 million potential doses at an expected cost of £3.7 billion.15 By the end of October 2021, it had eight agreements in place with six suppliers (Figure 7) for more than 340 million doses for delivery up to the end of 2022. (This includes vaccines already delivered and used in 2020 and 2021.) In September 2021, the Taskforce cancelled a contract with Valneva, which was for 60 million doses. Including the cancelled contract, total contracted costs at the end of October 2021 were £5.8 billion, of which £2.8 billion had been paid out.

2.7 Based on all the agreements in place in December 2020, we calculate a procurement cost per dose of £10.22 (including VAT) at that time.16 This could not have been expected to be an accurate predictor of future costs, as the original contracts were signed without any certainty of a viable vaccine being produced. As set out in paragraph 1.7, for all the agreements in place in October 2021 (including vaccines not approved or used in the UK), we estimate a procurement cost per dose of £15.02 (including VAT).17 This reflects the fact that there is a larger share of the more expensive vaccines now approved for use in the October 2021 portfolio. Currently, the UK does not have any contracts in place to purchase more AstraZeneca vaccine, which was the least expensive of the approved vaccines. Conversely, in November 2021, the Taskforce agreed to purchase an additional 114 million doses of the more expensive Pfizer and Moderna vaccines for use in both 2022 and 2023. This means that the average procurement cost per dose of a COVID-19 vaccine used in the UK is likely to increase further in future.

2.8 By the end of October 2021, 145.9 million doses had been supplied against the UK vaccine contracts, of which 126.8 million were for UK use. In the same time period, the Taskforce completed international donations (through the COVAX scheme or bilaterally) and other bilateral transfers, accounting for 19.1 million doses.18 The donations are part of the government’s commitment to donate 100 million doses to developing countries by June 2022.

2.9 Future UK demand for COVID-19 vaccines remains uncertain because of possible changes in the virus itself and clinical advice on who should be vaccinated and how often. There are future scenarios in which the government could end up with a surplus of vaccines but there is also the possibility of future gaps in supply. Assuming uptake of 85% and stock loss of 15%, we estimate that the UK needed around 170 million doses to meet all clinical advice accepted by the government up to the end of December 2021 (including second doses for 12- to 17-year-olds and booster doses for all adults and 16- to 17- year-olds). If a further booster dose were to be given to all adults during 2022 this would increase the need to around 220 million doses. As at the end of October 2021, the UK had contracts for around 340 million doses up to the end of 2022.

2.10 The Taskforce has already used a number of methods to optimise supply and reduce potential surpluses, including cancelling or rescheduling delivery (dependent on the terms of the contract), and international donations, and bilateral transfers or swaps with other countries as set out above (Figure 8 ).19 The Taskforce told us that the global market for COVID-19 vaccines remained “overheated” with many countries already securing supplies for 2023. The scale of the international COVID-19 vaccination effort is already double that of routine vaccines in a typical year, putting strain on underlying supply chains for materials such as glass vials and syringes. It is clear to us that the government can expect to take a very active approach to managing COVID-19 procurement for some time to come.

Vaccine distribution in England

2.11 By the end of October 2021, 49 million Pfizer doses, 40 million AstraZeneca doses and three million Moderna doses had been distributed to local sites in England. PHE, NHSE&I and three sub-contractors have worked together to store and distribute the vaccines, as set out in Figure 8.20,21 NHSE&I introduced a new digital management system, set up by Palantir using its software platform known as Foundry, to support the distribution effort and track how vaccine stock was being used.

2.12 From December 2020 until June 2021, the programme administered almost all doses to people just a short time after vaccines arrived in England, owing to limited supplies, the desire to vaccinate priority groups as quickly as possible, and the specific characteristics and handling requirements of each vaccine (Figure 9). The Taskforce told us it had aimed to hold at least two to three weeks of vaccine stock centrally at all times, with additional increases before new campaigns, for example for boosters or particular priority groups. Since June 2021, incoming vaccine supplies have exceeded demand by a much greater margin.

2.13 Initially, NHSE&I operated a ‘push model’ whereby it determined centrally the amount each local area received. It also required local vaccine providers to restrict future vaccination appointments based on known supply. During September and October 2021, NHSE&I rolled out a ‘pull model’ whereby vaccination sites can order the number of doses they think they will need. In our 10 local case study interviews, seven areas commented that it had been difficult not having enough local control and said a lot of work had been needed to get supplies to the right place under the push model; five said they found the pull model more helpful.

Problems with supply and distribution

2.14 The programme worked in a number of ways to manage potential disruptions to vaccine supply and their impact on rollout. The delivery schedules for the initial contracts were not binding but set out anticipated timetables which manufacturers were to do their best to meet. Schedules were generally confirmed only a month before delivery. The Taskforce told us its approach was to work collaboratively with manufacturers to address issues as they arose and to mitigate them where possible. During 2021, a number of disruptions or threats occurred in relation to supply chains, manufacturing capacity and international relations. Details of two of these are given in Figure 10.

2.15 In the first months of the rollout, supply was constrained and unpredictable, reflecting overall global supply. Feedback from local sites to NHSE&I and our 10 local case study interviews highlighted overall limitations in supply, short notice of deliveries, sudden cancellations of deliveries, and requests to take short-dated stock as the issues that had most often caused difficulties. Three interviews noted that in late 2021 some supply and distribution challenges remained. Many stakeholders told us that the problems had been overcome by the dedication and goodwill of everyone involved, from national bodies and contractors to local bodies such as GPs and pharmacies. The Taskforce, PHE and NHSE&I have met weekly to discuss supply and distribution issues.

2.16 UK Health Security Agency (UKHSA) officials told us that the split in responsibility for procurement, supply and distribution had at times created difficulties and led to inefficiencies. They gave examples of where they had not been sighted on procurement decisions that impacted on the storage and operational requirements for which it was responsible. This included changes to the size of vaccine packs and late or unexpected deliveries.

Managing wastage

2.17 Wastage can occur when vaccine is not handled in line with guidance (for instance regarding refrigeration) or cannot be used before its expiry date. The programme aimed to waste as little vaccine as possible. We heard in one local case study of vaccine centre staff often working late to use up spare doses rather than throw any away. Overall, by the end of October 2021, stock loss in the programme for England was an estimated 4.0% of all doses received (approximately 4.7 million doses), lower than the programme’s original planning assumption of 15%–20%.22,23 Specifically, wastage as a percentage of doses was:

0.5% within the national storage and distribution chain managed by PHE;

0.02% within the NHSE&I storage and distribution chain; and

4.5% at vaccination providers.

Our local case studies highlighted how potential wastage issues differed by vaccine type and delivery model. For example, restrictions on transferring Pfizer and Moderna vaccines between different sites had tended to increase wastage, as had some hospitals receiving larger packs of vaccines than they needed.

2.18 To reduce wastage, NHSE&I, in collaboration with regional pharmacists, approved transfers of COVID-19 vaccines between different local bodies. Normally, such transactions would be illegal under medicines legislation.24 In total NHSE&I estimated that 4.6 million doses had been transferred by the end of October 2021. In our local case study interviews, six participants noted the importance of these local transfers, although three considered that the process had been too slow and bureaucratic.

2.19 In August and September, the programme faced a particular challenge regarding expiring supplies of AstraZeneca vaccine. This followed the Joint Committee on Vaccination and Immunisation’s (JCVI’s) recommendation in May that those aged under 40 should preferably not be offered AstraZeneca. Unused AstraZeneca doses that had left the oversight of PHE and been sent to NHSE&I or local sites could not be returned due to restrictions on the handling of vaccines associated with quality assurance, and had to be destroyed. As a result, approximately 1.9 million doses had to be written off. The Taskforce, working with PHE and the Foreign, Commonwealth & Development Office, was able to avoid some wastage by redirecting 4.5 million AstraZeneca doses to other countries.

Success factors and future risks for procurement and supply

2.20 Figure 11 sets out our assessment of the strengths of the programme’s approach to procurement, supply and distribution at pace. We note particularly how the Taskforce and its partners worked with a clear strategy while acknowledging uncertainties and took a proactive and practical approach to dealing with potential barriers, adapting existing processes as required.

2.21 The course of the pandemic has continued to be unpredictable. The programme still has significant risks to manage when it comes to future supply, including changes to vaccines’ effectiveness against new variants, changes to future demand based on clinical advice, and the competitive global market. It will have to manage carefully any resulting surpluses and the increased risk of wastage. Our assessment of the key risks is in Figure 12.

13 As noted in paragraph 1.16, government and regulators adapted the normal procurement and approval procedures to speed up the vaccine development process, while still following regulatory requirements.

14 In our first report, which covered the first five contracts signed with vaccine manufacturers, we noted a wide range of costs and contract terms. There were variations in terms of the amount of upfront and non-refundable payments; the inclusion of priority access for the UK; delivery schedules; contract termination rights; the cost per dose; and inclusion of research and development costs. None of the contracts provided the UK with any rights to the intellectual property associated with the vaccines.

15 Comptroller and Auditor General, Investigation into preparations for potential COVID-19 vaccines, Session 2019-21, HC 1071, National Audit Office, December 2020.

16 The calculation is based on the total costs of the vaccine contracts and other agreements (including VAT) in place by the end of December 2020, divided by the number of doses contracted for. Exchange rates used are as at the end of October 2021 as the Taskforce does not hedge its foreign exchange exposure.

17 See footnote 6 for details of how this cost per dose was calculated.

18 The COVAX scheme is co-led by the World Health Organization (WHO) and others alongside delivery partner UNICEF, to facilitate sharing and donating COVID-19 vaccine doses between countries and manufacturers.

19 The Taskforce and the Foreign, Commonwealth & Development Office make and implement decisions on dose sharing between different countries.

20 All of the COVID-19 vaccines have particular storage and handling requirements, including: the need for ultra-low or normal freezer transportation and storage; and limits in how many times they can be handled by different parties. Pfizer also initially came in a large pack size that needed to be broken down before delivery to smaller vaccination sites. In May 2021, the Medicines and Healthcare products Regulatory Agency (MHRA) extended the shelf-life of the Pfizer vaccine from five days to 31 days once thawed, allowing much more flexibility in storage and usage. Following an audit of security arrangements for transportation and storage and updated advice from DHSC, some newer vaccination venues increased security measures.

21 PHE also procured and supplied additional consumables which were required by vaccination sites, such as needles and syringes.

22 NHSE&I based this planning assumption on the handling characteristics of the Pfizer vaccine, which included very high expected wastage rates for some delivery models, for example, up to 80% for roving models. The overall stock loss calculation for England is estimated, based on stock loss figures from NHSE&I and adjusted figures from PHE, to take into account the fact that it handles vaccines for the whole of the UK. The specific PHE stock loss figure given above is unadjusted and is for the UK. This calculation cannot take into account possible stock loss for those vaccines which have not yet been delivered to sites or used, which could increase the overall percentage of stock loss for vaccines received.

23 Previous rates for routine vaccinations (excluding seasonal ones such as influenza) vary between 1%–2%.

24 MHRA noted that, in anticipation of the need to move COVID-19 vaccines from one site to another, it had amended the legislation for the purposes of public health to allow these transfers.

Part Three

Vaccine deployment and uptake

3.1 This part of the report looks at the rollout of COVID-19 vaccination, including:

overall progress with COVID-19 vaccination;

how national and local bodies delivered COVID-19 vaccination;

actions to address differences in uptake for different population groups; and

success factors and future risks for COVID-19 vaccine deployment.

3.2 NHS England and NHS Improvement (NHSE&I) led on the COVID-19 vaccine deployment programme, working with local health bodies and care providers, and national bodies such as Public Health England (PHE).

Main stages of the rollout

3.3 Government accepted the recommendations of the Joint Committee on Vaccination and Immunisation (JCVI), which provides independent clinical advice, on how and to whom vaccines should be administered, as well as that of the Chief Medical Officers. In particular, JCVI advised on the order in which population groups were offered vaccines (Figure 13).

3.4 The rollout has fallen into three main phases (Figure 14):

Phase 1, starting on 8 December 2020, aimed to vaccinate the greatest number of at-risk people in the shortest possible time. It covered the first nine priority groups, around 27 million people in England. This included health and care workers, those over the age of 50, those considered clinically extremely vulnerable, and those aged over 16 with underlying health conditions (Figure 13). All were to receive two doses.25

Phase 2, beginning in April 2021, extended vaccination with two doses to priority groups 10 to 12, comprising those aged 18–49.26

Phase 3 extended vaccination with a single dose to most 16- and 17-year-olds (from August) and 12- to 15-year-olds (from September).27 Phase 3 also initiated the rollout of booster vaccines from September and third primary doses for those who are severely immunocompromised.28 The booster campaign is not evaluated in this report.

Overall progress against commitments

3.5 Overall uptake exceeded NHSE&I’s initial planning assumption that 75% of adults would come forward for both doses. By the end of October 2021, 85% of adults (aged 18 and over) had had two doses. Uptake for younger people was lower, with 62% of 16- to 17-year-olds and 25% of 12- to 15-year-olds receiving a first dose, although this likely reflects in part the later rollout start for these age groups. The 85% uptake rate for adults in England compared well with those in other home nations and European Union countries, which ranged between 76% and 93% (Figure 15).29

3.6 At its peak in March, the programme delivered 3.5 million doses in a week. By the end of October 2021, it had administered more than 87 million doses in England, about six times the number of flu vaccine doses administered during 2019-20. This comprised 42 million first doses, 38 million second doses, and seven million booster or third doses.

3.7 The government made a number of public commitments on rollout, focused on how quickly groups would be offered the vaccine (Figure 16). Up to July 2021, NHSE&I and its delivery partners achieved all their major deployment targets, including offering vaccines in all care homes by 31 January, to the first four priority groups by 15 February, and to the first nine priority groups by 15 April 2021, and vaccinating two-thirds of all adults by 19 July.

3.8 NHSE&I did not meet some later objectives. While the programme almost met the target to make offers to all 12- to 15-year-olds by October half-term, it did not achieve its objective to vaccinate the majority of them. By the end of October 2021, it had succeeded in giving first doses to only 25% of the age group. The intended primary deployment model for this age group was School Age Immunisation Services (SAIS) and this was part of the reason for the slow rollout. The Department of Health & Social Care (DHSC) noted that it had also taken longer than expected to gain consent from parents, potentially requiring multiple school visits. Local case study interviews also described issues with consent procedures alongside other reasons for delay including the high number of infections among the age group at that time. On 19 October, NHSE&I enabled appointment booking for 12- to 15-year-olds via the National Booking Service (NBS). At the end of January 2022, 58% of 12- to 15-year-olds had received a first dose.

Approach to deployment

The use of different delivery models

3.9 The UK Vaccines Delivery Plan, published in January 2021, set out three main routes through which the public could get vaccinated, with the aim of catering to different preferences and making access as easy as possible:

Hospital hubs, based at NHS trusts, which primarily vaccinated health and care staff.

Local vaccination services, comprising groups of primary care networks, led by GPs, and community pharmacies, which comprised the majority of locations.30 These included a wide variety of different services and settings such as: mobile services, pop-up and walk-in clinics (see also paragraph 3.27).

Vaccination centres, set up specifically for COVID-19 vaccinations and based in venues such as stadiums, theatres and hotels. Centres could be run by NHS trusts, primary care networks or pharmacies.

3.10 NHSE&I initially planned on the basis that 41% of vaccinations would be delivered at vaccination centres, 56% by GPs and community pharmacies and 3% in hospitals. By the end of October, only 21% of first and second doses had been delivered at vaccination centres and 71% by GPs and pharmacies (mostly GPs, at 56%). In total, GPs had administered 44.5 million doses by the end of October (Figure 17). Healthwatch has reported that public trust was higher in medical professionals when there was an existing relationship, which may help to explain the popularity of local vaccination services.

3.11 The use of multiple delivery models was a deliberate choice which has improved accessibility and helped to vaccinate as many people as quickly as possible but this has increased costs. Figure 18 shows how different priority groups used different delivery models to receive their vaccines: across all groups, local vaccination services were used most, with people aged under 65 more likely than others to use vaccination centres. NHSE&I assumed that GP and pharmacy routes, and vaccination centres would be the most expensive of the main delivery models at £37 and £36 per dose respectively, in part reflecting different staffing requirements.31 Overall, costs per dose have been lower than anticipated. However, vaccination centres have ended up being the most expensive model at £34 per dose, compared with £24 per dose for GPs and community pharmacies (Figure 19). NHSE&I told us that this was due to a variety of operational factors including the need to establish new clinical facilities, short-term leases of venues, recruitment and training of temporary staff and fluctuations in demand. Vaccination centres have also operated at only half their planned output.

3.12 Some of our local case study interviewees told us that the multiple routes to access could also create tensions and competition between providers and, at times, confusion for some members of the public. NHSE&I’s own review found that local stakeholders felt that those centrally running the vaccination programme sometimes failed to listen to experiences from the front-line and adapt and change their processes accordingly. NHSE&I did highlight to us examples of the national team improving processes in response to feedback, such as changes to how local areas could order vaccines (paragraph 2.13).

3.13 In November 2020, the programme estimated that the national workforce employed on COVID-19 vaccination would need to peak in January 2021 at more than 45,000 full-time equivalent positions (60,000 part-time vaccinators and 65,000 part-time non-clinical staff). DHSC and NHSE&I took steps to secure this workforce including: legislating to allow a wider group of healthcare professionals (for example, physiotherapists) to administer vaccines; recruiting around 25,000 clinical volunteers through St John Ambulance; recruiting around 92,000 non-clinical volunteers through the national NHS Volunteer Responders programme (run by the Royal Voluntary Service (RVS) and GoodSam); and getting support from the armed forces. Through NHS Professionals, around 21,000 paid staff were recruited as clinical and non-clinical vaccinators and registered healthcare professionals.

3.14 Local case study areas we interviewed were positive about the contribution of local staff and volunteers. In six out of 10 interviews, respondents said they had enough staff in the initial stages, while four noted shortages of nurses or people recording consent. St John Ambulance and the RVS said their volunteers had initially been under-used in some areas. NHSE&I data shows that only 23% of the volunteers it recruited had been utilised by June 2021.

3.15 Some local case study areas had seen staffing become more of an issue as the economy returned towards normal in the second half of 2021 and healthcare professionals became needed elsewhere. They also reported fears about the risk of burnout given the sustained pressure on some staff. UKHSA noted that the COVID-19 vaccination effort had diverted staff and other resources away from routine school vaccinations and this was also flagged as a risk by the JVCI and the Chief Medical Officers.

The role of clinical advice

3.16 NHSE&I had to ensure that the programme was in line with Medicines and Healthcare products Regulatory Agency (MHRA) regulations and any subsequent advice and followed clinical advice from the JCVI and the Chief Medical Officers, as accepted by ministers. This has determined who is eligible and should be prioritised for vaccination, vaccination type and all clinical aspects of the programme. For example, advice on intervals between first and second doses changed over time to allow a maximum of three to four weeks, then 12 weeks and then eight weeks between doses. As further evidence became available on the efficacy and safety of the COVID-19 vaccines and in the light of developments in the pandemic such as new virus variants, advice has continued to change over time (Figure 14). These changes often had to be implemented at very short notice. For example, on 7 April 2021, reflecting information about a possible link between the AstraZeneca vaccine and the risk of rare blood clots, JCVI issued new advice that people aged under 30 should be offered an alternative to AstraZeneca where available (this was extended to people under 40 on 7 May). NHSE&I had to rapidly communicate the policy and operational changes required, and its delivery partners had to make healthcare professionals available immediately to support conversations about the choice of vaccine for appointments which could not be cancelled the following day.

3.17 Stakeholders told us that goodwill, flexibility and determination had been essential in a fast-changing situation. But, from our local case studies and local feedback gathered by NHSE&I, there was widespread frustration with changing messages and the speed with which some changes had to be implemented. A particular frustration was the fact that programme changes were often announced in the media before NHSE&I had communicated them to local providers. For example, this was the case with offering vaccinations to 12- to 15-year-olds outside school settings. Local case study areas were left with little or no time to prepare and updated guidance was not always available before members of the public began to demand what had been announced. NHSE&I told us that it was unable to communicate in advance with local sites owing to the confidential nature of the updated advice.

Use of data and digital systems

3.18 The COVID-19 vaccine programme, supported by NHS Digital, set up a national integrated data system, making use of the existing national immunisation management system that allowed the NHS to identify, record and transmit all patient vaccination data, including vaccination status, across the health and care system for the first time. This included the ‘point of care’ system, where details about the individual and type of vaccination administered were recorded when people were vaccinated.32 NHS Digital also set up a national online booking system, primarily for vaccination centres and community pharmacies.33 Stakeholders told us that the booking system was generally an effective innovation which helped to expand convenient access; but some found that a lack of flexibility (for example, difficulty in cancelling bookings) and the lack of a single booking system for all types of location made it difficult for some sites to manage their workload. NHS Digital told us that it has continued to make changes to the booking system over time in response to feedback from users.

3.19 NHS Digital took what it described as a “modular” approach, building on existing systems to set up quickly the system for the vaccination programme. It has subsequently developed this into a streamlined template, which it is considering using in other vaccination programmes.

3.20 From December 2020, NHSE&I also used the Foundry software to support the programme’s day-to-day operations. This enabled pre-existing data (for example, GP and hospital patient data) to be combined with new data collected through the COVID-19 vaccination programme in real-time. It allowed analysis of vaccination delivery and uptake by site, region and local area, and individual characteristics such as ethnicity and JCVI-defined priority groups. The identification of priority groups was not always easy from established data, requiring creative use of multiple data sources, including in some cases local authority data. NHSE&I’s programme leadership team dedicated time every morning to reviewing Foundry data. It was used to manage key programme risks and to monitor divergence from central directions, for instance identifying local areas that were providing second doses too early.

3.21 From January/February 2021, local health systems and local authorities have also been able to use a version of Foundry to model demand and capacity for their sites, and to benchmark themselves against similar areas to gain greater understanding of vaccine inequalities. From April, primary care networks and pharmacies had access to information on vaccination numbers. In our local case study interviews, four out of 10 said they had found Foundry useful in trying to address inequalities. Five used their own information sources and others noted limitations such as issues around access to data or coverage gaps.

Addressing differences in vaccine uptake

3.22 The programme has generally achieved high uptake but differences between groups have persisted. Up to the end of October, 85% of adults had received two doses of COVID-19 vaccines. This is substantially higher than the uptake for single-dose flu vaccines in 2019-20 (72% for people aged 65 and over, 45% for people aged under 65 in a clinical risk group, 44% for pregnant women and 74% for front-line health and care workers). However, some priority groups had a much slower rate of vaccination (Figure 20) and uptake is lower than average for some groups (see paragraph 3.25).

3.23 Priority groups 1 and 2 include front-line social care workers, but there is no central register of the social care workforce. In order to ensure access for this group, NHSE&I took the decision to make the National Booking Service (NBS) available to care staff a few days before the deadline, rather than sending personal invitations to each worker. The Scientific Advisory Group for Emergencies (SAGE) advises that an uptake rate for one dose of 80% in staff and 90% in residents in a care home is needed to provide a minimum level of protection against COVID-19 outbreaks. By June 2021, only 65% of older adult care homes in England were meeting the minimum level for staff uptake. This led the government to introduce mandatory vaccination as a condition of deployment for care home staff, which came into force from November 2021.34 Care sector and local government stakeholders told us that they were very concerned about the consequences of this legislation on recruitment and retention. As at 31 October, 89% of staff at older adult care homes had received two doses of a vaccine, with 85% of older adult care homes meeting the protection levels set by SAGE.

3.24 Priority group 6 comprised unpaid carers and those with underlying health conditions which put them at higher risk. The rollout to this group proceeded relatively slowly. It was challenging for NHSE&I to identify this group from its national data systems, requiring five different data sources to be analysed (GP at-risk or carer records, the GP Learning Disability Register, the QCOVID assessment tool, and local authority and carer’s allowance records).35 Carers UK highlighted particular issues in identifying unpaid carers. Unpaid carers had been encouraged to register as such with their GPs, but GP guidance was not always updated quickly enough. For a short period, individuals could self-identify via the NBS but this was limited due to concern about the risk of misuse. By the end of October 2021, the estimated percentage of people in priority group 6 who had received two doses of a vaccine was 81%.

3.25 Previous vaccination programmes have shown that uptake varies for different groups and in complex ways. Figure 21 shows how COVID-19 vaccination rates varied at the end of October 2021, the point by which all adults could have had two doses. In particular:

rates were above 90% in all over-50 age groups but substantially lower for those aged 18 to 24 (64%) and 25 to 29 (68%);

rates for adults were lower among more deprived parts of the population; and

some ethnic groups had very low levels of vaccination relative to the national rate for adults based on a slightly different uptake measure than the one for age groups: rates were lowest among adults of Chinese (48%), Black Caribbean (49%), or Black Other (49%) origin, compared with 76% for all ethnic origins.36

3.26 The vaccines programme and other parts of government have undertaken a range of actions to try to increase uptake of COVID-19 vaccinations in different groups. Up to the end of October 2021, these have included:37

producing a range of general and targeted material, including the UK COVID-19 Vaccine Uptake Plan and other guidance, standard operating procedures, mobilisation packs for specific settings such as care homes, and information leaflets;

sharing good practice between regions and local areas;

cross-government communication campaigns to increase confidence in the safety of COVID-19 vaccines and counter disinformation. These campaigns identified and focused on groups that are more likely to be vaccine-resistant or hesitant. They sought to influence them through people they trusted, for example clinicians, scientists and community leaders, and through a range of platforms, including TV, social media sites and particular newspapers;

providing funding of £7.2 million to local health systems to allow them to take targeted action to increase uptake and reduce inequalities in their areas. Outside the vaccine programme, government also provided funding of £23.75 million to local authorities through the Community Champions Scheme, which they could use to promote vaccine uptake and provide information about vaccine safety. This funding was partly used to recruit faith and community leaders to promote vaccines within their communities; and

setting up a taskforce in summer 2021 to help improve uptake. The Vaccine Uptake Taskforce brought together operational, communications, behavioural insight and regional expertise, to increase central government’s focus on reaching the unvaccinated.

3.27 Figure 18 above shows that different priority groups varied in terms of which delivery model they used to receive their vaccine. In line with the national strategy, local areas used a wide variety of approaches to increase access and uptake, particularly for those in deprived communities where ethnic minority groups tend to be concentrated. For example, our three local case study areas gave examples of mobile services, pop-up and walk-in clinics, clinics for specific groups (for example, women-only); working with community leaders and youth champions; using locations such as mosques, cafes and community centres; and different ways of communicating such as social media and door-knocking. However, in seven of our ten case study interviews, we heard that there could be tensions between national directions and local priorities, for example, one area was discouraged from inviting people to come forward to check their eligibility to be vaccinated, while another noted that central processes for accrediting new approaches (for example, buses) hampered local initiatives. Examples of actions targeted at particular groups are given in Figure 22.

3.28 It is often difficult to attribute specific measurable impacts to individual public health campaigns or other activities. Generally during 2021, Office for National Statistics (ONS) research suggests increasing levels of vaccine confidence, with 84% of adults reporting positive sentiment towards a COVID-19 vaccine in December 2020–January 2021 and 96% in June–July 2021.38 Inequalities persisted, but could have been still greater if the actions described had not been taken. The Cabinet Office found high awareness of central government media campaigns, and there is some qualitative evidence that national campaigns in the summer helped to increase uptake among younger age groups. But overall, government has not yet identified how it can fully overcome persistent inequalities. Stakeholders told us that, for some communities, pre-existing lack of access to, engagement with, or trust in health services had been difficult to overcome, and they also emphasised the importance of supporting local initiatives and conversations.

Success factors and future risks for deployment and uptake

3.29 Figure 23 sets out our assessment of the strengths of the programme’s approach to administering COVID-19 vaccines at speed. Again, we note the particular value of the programme’s early clarity of purpose and prioritisation, and having explicit objectives related to speed. We think the balance between using existing infrastructure, data, skills and systems and making targeted innovations worked well, as did the conscious choice to set up a range of different routes for the public to access vaccinations. At national and local levels, we saw evidence of a culture of learning and continuous improvement, for example sharing lessons with regions and providers, and interim reviews of and adaptations to approaches.

3.30 While there was broad agreement across many stakeholders that the programme had engaged well with them and an acceptance of the need for a centralised approach, UKHSA, primary care representatives and some local government stakeholders did not feel their existing experience and knowledge had been taken fully into account at an early enough stage. In particular, the British Medical Association, representing GPs, told us that it was fully engaged in planning from October 2020 onwards, but it felt if this had happened earlier some difficulties with logistics, communications and IT systems could have been avoided.

Risks

3.31 The programme needs to manage a number of risks to ensure delivery of its immediate objectives while also beginning to consider a future sustainable model for COVID-19 vaccinations. Figure 24 sets out our assessment of the main risks. In particular, we note the risk that continuing intensive delivery of vaccinations poses for staff capacity and welfare and the NHS’s other priorities. We also note the urgent need to make more progress in vaccinating those groups with lower uptake.

Developments in deployment after October 2021

3.32 The vaccine programme has continued to change, with new demands being placed on those administering vaccinations throughout the autumn and winter of 2021. In September 2021, the booster campaign started for the first nine priority groups. Following the emergence of the Omicron variant, boosters were then extended to everyone aged 18 and over, with a target to offer all adults a booster, first, by the end of January 2022, and then, by the end of December 2021. To allow faster delivery, the government announced changes to deployment, including reducing the interval between booster and initial vaccinations from six months to three; increasing payments to GPs and community pharmacies; opening more sites; and drawing on the military for additional support. To meet the end of December target, some NHS and primary care staff were redeployed away from routine services. In addition, all 12- to 17-year-olds are now eligible for a second dose, and 16- to 17-year-olds are eligible for a booster. In December 2021, JCVI advised vaccination for some 5- to 11-year-olds and booster vaccinations for some 12- to 15-year-olds (broadly those at clinical risk themselves or in a household with someone who is immunosuppressed). The programme also continues to offer doses to anyone not yet vaccinated.

3.33 As at the end of January 2022, 88% of adults had received two doses, and 70% a third dose or booster vaccination. An estimated 8%, or around 3.7 million adults, were unvaccinated. By the same point, around 58% of 12- to 15-year-olds had received a first dose, as had 73% of 16- to 17-year-olds.

25 Of the COVID-19 vaccines approved for use in the UK, the recommended primary course for adults is two doses for Pfizer, AstraZeneca or Moderna. The recommended primary course for the Janssen vaccine is one dose, but this has not been rolled out in England to date.

26 Phase 2 also covered the rollout of third vaccine doses (as distinct from booster vaccinations) for people aged 12 and over who were severely immunocompromised, at least eight weeks after their second dose.

27 In Phase 3, COVID-19 vaccines were first rolled out to all 16- to 17-year olds, as well as 12- to 15-year-olds with specific underlying health conditions that put them at risk of severe COVID-19, or who were household contacts of persons who are immunosuppressed. This was later expanded to all 12-to 15-year-olds. In November 2021, the government accepted JCVI advice for a second dose for 12- to 15-year-olds and 16- to 17-year-olds.

28 The initial advice was for a one-dose booster vaccination for priority groups 1–9, six months after completion of their initial vaccine course. By November 2021, government had accepted further JCVI advice that all adults aged 18 and over should receive the booster, with the interval between second doses and booster shots reduced from six months to three.

29 We compare uptake rates for those aged 18 and over, as rollouts for those aged under 18 started later in some countries and were at different stages at the time of writing this report.

30 Primary care networks are networks of GP practices. They were established in 2019 across the NHS as part of the NHS Long Term Plan to support care integration in their local communities, including working more closely with their local NHS acute service providers.

31 NHSE&I anticipated that vaccination centres would require 149 members of staff, compared with 24 for GPs or pharmacies or three in hospitals. These estimates included workforce and estates costs as well as an apportionment of all other central costs of the vaccination programme.

32 The NHS Digital systems require a patient to have an NHS number for their vaccination to be recorded and reported. Without an NHS number, a vaccination may have to be recorded manually. NHS Digital estimated that around 1.5 million people in England do not have an NHS number. It is currently exploring options to allow people without an NHS number to be entered in the system when a vaccination is given, for example, through allocation of a new NHS number if a patient is willing to do so.

33 The national booking system was the only online system available for vaccination centres and pharmacies. GP and hospital providers were initially outside the national booking system and had to use their own IT systems to manage appointments, but were later able to opt in to use the national system.

34 In November 2021, government extended mandatory vaccination as a condition of employment to all front-line health and social care workers, effective from April 2022. In January 2022, it announced that it would revoke this policy for health and social care staff, subject to consultation and Parliamentary approval, in light of the emergence of the Omicron variant.

35 QCOVID is a clinical decision tool intended to support conversations between clinically trained professionals and patients about COVID-19 risk. It was developed as a model to estimate a person’s risk of being hospitalised or dying due to catching coronavirus.

36 In this report, most measures of uptake use mid-2020 population estimates from the Office for National Statistics as a denominator. However, uptake by ethnicity uses population estimates from the National Immunisation Management System. The different levels of uptake by ethnicity could be in part due to their different age profiles and could also be related to levels of deprivation. We have not adjusted for these factors in our analysis by ethnicity.

37 Paragraphs 3.9 to 3.15 cover the actions government took to set up the system for people to be invited for, book and get a vaccination, and 3.18 to 3.21 cover actions relating to collating, monitoring and sharing data.

38 Positive sentiment included respondents who said that they had received the vaccine or had been offered the vaccine and were waiting to be vaccinated, or that they were very or fairly likely to have the vaccine if offered.

Appendix One

Our audit approach

1 This report examines whether the government is well placed to meet its full objectives for the COVID-19 vaccination programme in England. It follows our December 2020 report Investigation into preparations for potential COVID-19 vaccines.39 The current report builds on our December 2020 investigation to evaluate the COVID-19 vaccination programme up to the end of October 2021.

2 The report covers:

what progress the programme made in procurement and deployment up to the end of October 2021;

what contributed to the programme achieving its initial objectives; and

what are the future risks for the programme.

3 The report focuses on England, with the exception of procurement which the government has done on a UK-wide basis. We describe but do not evaluate in depth:

the content and timing of clinical advice, including on regulatory, approval and safety matters, as issued by the Medicines and Healthcare products Regulatory Agency, Joint Committee on Vaccination and Immunisation or the Chief Medical Officers. These bodies are not formally part of the vaccine programme or its implementation. Their advice was independent, which ministers could then accept and direct the vaccines programme to implement;

vaccine certification and ‘passports’ – these are dependent on information from the vaccines programme, but the main focus of the report is on the process for people to receive a vaccination; and

events after October 2021 – the period up to the end of October 2021 covered the main NHS targets for rolling out two doses to all adults in England, and single doses to 12- to 17- year-olds (as initially only one dose was recommended). The report does not cover the booster programme in depth as, although this started prior to October 2021, it was envisaged at the outset that this would take some months to complete.

4 We applied an analytical framework with evaluative criteria that considered what arrangements would be optimal for achieving value for money. By ‘optimal’ we mean the most desirable possible, while taking into account the context of the programme, and any specific restrictions or constraints.

5 Our audit approach is summarised in Figure 25 and our evidence base is described in Appendix Two.

39 Comptroller and Auditor General, Investigation into preparations for potential COVID-19 vaccines, Session 2019-2021, HC 1071, National Audit Office, December 2020.

Appendix Two

Our evidence base

1 We reached our independent conclusions on the COVID-19 vaccination programme in England after analysing evidence collected between July and November 2021. Our audit approach is outlined in Appendix One.

Government interviews

2 We interviewed staff, mostly those with a strategic or operational view of the COVID-19 vaccination programme, in those government departments directly responsible for the programme, including the Department of Health & Social Care (DHSC), the Department for Business, Energy & Industrial Strategy (BEIS), NHS England and NHS Improvement (NHSE&I), the Vaccine Taskforce (the Taskforce), Public Health England (PHE), UK Health Security Agency (UKHSA) and NHS Digital. We also interviewed other departments involved in the delivery of the programme, including the Department for Digital, Culture, Media & Sport, the Cabinet Office, Her Majesty’s Prison and Probation Services, as well as the Office for National Statistics (ONS). We also spoke to the UK regulator the Medicines and Healthcare products Regulatory Agency (MHRA).

Stakeholder interviews

3 We carried out stakeholder interviews to understand external views about the programme and its effectiveness, including with the British Medical Association, Care England, Carers UK, Healthwatch England, Homeless Link, Mental Health Consortia, National Pharmacy Association, NHS Providers, Race Equality Foundation, Refugee Council, Royal College of General Practitioners, Royal Voluntary Service, St John Ambulance, Local Government Association, and United Kingdom Homecare Association. We reviewed documents and reports supplied from some of these stakeholders or published online.

Document review

4 We reviewed a range of documents from government departments and their agencies against our main study questions, and particularly to understand progress and developments in the COVID-19 vaccination programme and its plans. This included published material and internal documents accessed under our statutory audit rights, such as ministerial submissions, business plans and cases, board papers and minutes, financial and management reports, internal and external communications, contract information, internal reviews and evaluations of the programme, guidance, and documents published by the Joint Committee on Vaccination and Immunisation (JCVI) and MHRA. We also reviewed publications on COVID-19 vaccinations published by some academic bodies, the World Health Organization and European Medicines Agency.

Data analysis

5 We analysed data from a range of sources to understand the operational and financial performance of the vaccination programme. This included publicly available data from NHSE&I, PHE and UKHSA, ONS, NHS Digital, MHRA and the European Centre for Disease Prevention and Control; and, internal reporting on performance, finance and contracts, and key performance indicators and metrics from DHSC, the Taskforce, NHSE&I, PHE, UKHSA and NHS Digital.

Local case studies

6 We conducted 10 interviews with frontline teams working on the COVID-19 vaccination programme locally, from a sample of three areas: Tower Hamlets, Gloucestershire and Bolton. We interviewed staff who were responsible for delivery of the vaccination programme in their local area, representing clinical commissioning groups, local authorities, NHS trusts, GPs and pharmacies. This included staff responsible for setting up and running vaccine centres. This work was designed to understand:

how the vaccination programme was rolled out locally in practice, including progress made, success factors and challenges faced by local systems in the rollout to date;

their engagement with, and the effectiveness of support by, national bodies; and

future risks faced by local systems as the vaccination programme continues.

Limitations of the evidence

7 The analysis and findings in this report reflect our best understanding at the time of the report, but there are limitations and uncertainty in the completeness and quality of the financial and contractual information available to us. Funding, costs and contracts data are based on internal management information, both audited and unaudited. However, relevant bodies have reviewed and confirmed the accuracy of information relating to them as reflective of their best knowledge at the time of this report. As the programme continues, and further internal assurance work is carried out and payment for aspects of the programme is finalised, some of the figures included in this report may be subject to change.

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