The government intends to bring in mandatory Covid-19 vaccination for all frontline NHS staff from next April. This is something that sits very uncomfortably with many occupational health professionals. Nic Paton reports.
The announcement this month by health secretary Sajid Javid that NHS staff in England will be required to be fully vaccinated against Covid-19 by April 2022 could end up becoming a logistical ‘nightmare’ for already hard-pressed NHS occupational health teams, practitioners have warned.
Under the plan, all full-time NHS staff in patient-facing roles will be expected to have received coronavirus jabs as a condition of employment, unless they have a medical exemption, by 1 April 2022 – subject to parliamentary approval.
Javid called on employers to “support and encourage” employees to get vaccinated. “No one in the NHS should be scapegoated, singled out or shamed [for not getting a vaccine so far],” he said.
For many OH NHS practitioners, however, the worry is that they may end up finding themselves caught between vaccine-hesitant or reluctant employees, those with genuine medical or other exemptions, and employers wanting to crack on with getting the vaccine mandate over the line.
“It’s going to be a nightmare sifting through all the advice requests from people who don’t want the vaccine, never mind people that think they will be exempt on medical grounds but aren’t,” one member of the occupational health practitioners’ Facebook group told OHW+.
Mandatory Covid vaccination
“Absolutely agree that, if medically exempt staff need to present their own evidence to management, it will become unwieldy,” said another.
“OH will need to be able to deliver alongside other vaccines,” agreed a further practitioner.
For Professor Steve Nimmo, president of the Faculty of Occupational Medicine, the decision also raises important ethical and consent questions for the profession.
When the idea of compulsory vaccination of care home staff was first mooted last summer (and which came into effect this month) the faculty published guidance on testing and vaccination, which set out a firm position against going down the mandatory route. See the end of this article for more on this.
“One reason why we are not in favour of it [mandatory vaccination], is that we’ve been vaccinating people for things like hepatitis B forever, and we’ve never needed compulsion to do that,” Professor Nimmo tells OHW+.
“The other reason that we are wary of this is that there is pretty good evidence that compulsion increases vaccine refusal. And it also creates soapboxes for anti-vaxxers,” he says.
There is pretty good evidence that compulsion increases vaccine refusal. And it also creates soapboxes for anti-vaxxers” – Professor Steve Nimmo
Concerns around vaccine refusal
The fact NMC and GMC codes of conduct spell out that any regulated professionals have to protect their patients against transmissible diseases should mean anyone who is regulated – doctors, nurses, physios and so on – will be expected to have the vaccination anyway.
Having worked as a consultant in an NHS trust for the past 18 years, Professor Nimmo agrees he cannot remember a doctor or nurse ever refusing a vaccination, unless there was a contra-indication. “So, I don’t actually see that this is going to be a problem with the doctors and nurses. Where it may be a problem is the healthcare assistants and the carers; these are the people who are most likely to say no.
“This is a government policy; this is not about protecting members of staff, it is about protecting patients. So I would not see it [enforcing mandatory vaccination] as being part of my role. The really important thing here is that we, occupational health, must play no role in anything disciplinary.
“We mustn’t be seen as being the executive arm of HR. We mustn’t be seen as the people who wield the disciplinary policy. We probably wouldn’t even be involved in telling HR who has been vaccinated and who hasn’t without informed consent and assurances on how the information will be used,” Professor Nimmo adds.
Health education and advocacy role?
For Neil Loach, president of iOH, The Association of Occupational Health and Wellbeing Professionals, and senior lecturer at the University of Derby, the ‘stick’ approach of making Covid-19 vaccination mandatory is also deeply problematic.
“No other vaccination is mandatory. Many other diseases have killed far more people in the past than Covid. So, from a moral point of view, why should you put pressure on people who are already under pressure, people who are already feeling a bit burnt out or at the end of their tether? And then suddenly say, ‘right, OK, if you don’t have the vaccine, you’re out of a job’, because, ultimately, that’s what it would be,” he questions.
Occupational health could nevertheless still play an important health education and vaccine advocacy role to win hearts and minds and so accelerate voluntary vaccination, he emphasises.
We’ve got a terrific mountain to climb and the morality of making it mandatory is questionable.” – Neil Loach
“I think there is a role for occupational health in that, in terms of if somebody feels they don’t want to have it from a health perspective, then there needs to be some kind of programme of health promotion or education because there is still a lot of ignorance around vaccination,” he says, though adding that adding a mandatory line in the sand does bring an added element of difficulty.
“I think we need some kind of package or information. We need to sit down and talk to people and listen to what their fears are. The difficulty is time. OH within the NHS is often small departments; they are usually under-funded; they will often be short of qualified SCPHNs. We’ve got a terrific mountain to climb and the morality of making it mandatory is questionable.
“If we can get across that message of ‘look after the NHS, yourself, and look after your family’ it needs to go back to that, because people don’t understand the importance of being vaccinated. Then, we’ve got the added complexity of we don’t know enough about how effective the vaccine is going to be and for how long. There are still many unanswered questions and that puts us sometimes in a very difficult position to be able to talk with authority. It is going to be very challenging,” Loach adds.
The Faculty of Occupational Medicine’s guidance on vaccination and testing published over the summer made its position very clear when it comes to mandatory vaccination.
Occupational health professionals should encourage the uptake of Covid-19 vaccines “on a voluntary basis”, it said.
“Making a vaccine mandatory is a policy decision. The FOM is not supportive of mandatory vaccination as a condition of employment. An ‘inform and consent’ approach together with organisational leadership and reiterating professional responsibility of staff is very likely to achieve an excellent uptake whereas mandating the vaccine poses ethical and practical challenges and may increase vaccine hesitancy,” it added.
This position was echoed by the Academy of Medical Royal Colleges in July, which emphasised it “firmly” believed all health and care staff “should choose to be vaccinated.”
“While we understand the rationale for mandating NHS staff vaccination, our view is that making any vaccination mandatory is not sensible or necessary,” it said.
“We believe that in practical terms mandatory vaccinations will cause real difficulties with unnecessary disputes and arguments at local and national level. The danger is that individual arguments become a distraction from the core issues of getting as many of the population vaccinated as possible,” it added.
Of the decision to move to mandatory vaccination from April 2022, the British Medical Association said putting the six-month delay in place was “sensible” ahead of expected winter pressures on the service.
Dr Chaand Nagpaul, BMA council chair, said: “While the BMA has serious concerns about making vaccination mandatory, we’re pleased that the government has, as we recommended, decided to delay the policy of mandatory vaccination for Covid-19 until spring next year, and released both its workforce impact assessment and it’s equality impact assessment.
“Given the current staffing crisis in the NHS and the possible implications of trying to introduce such measures in the midst of winter pressures, waiting until April is sensible, but it’s equally important that the government is aware of the consequences this policy could have even after the delay – and that clear steps are taken to mitigate this risk.
“Even if a small number of staff were forced out of work because they are not vaccinated though, this would have a big impact on a health service that’s now under constant pressure and already has more than 93,000 unfilled vacancies.”
And Rebecca Thornley-Gibson, a partner at law firm DMH Stallard, has said the move could lead to legal disputes. “Unless the NHS is going to insist that all visitors, including contractors and suppliers, have to be fully vaccinated to attend hospital, I can foresee logical arguments from non-patient facing staff that the requirements are unfair.”