Steve Russell: Vaccination should be more present in national discourse

Matthew Taylor

I'm delighted to be joined by Steve Russell, who's chief delivery officer at NHS England, national director for vaccination and screenings, and Steve is someone that we work with a lot at the Confederation, particularly around the work of our ICS network. 

Steve joined NHS England in February 2022 to lead the NHS COVID-19 vaccination and flu programmes and before that Steve had an extensive career in the NHS, culminating in being chief executive of Harrogate and District NHS Foundation Trust just up the road from me here in York. 

But what we're going to be doing today is talking all about vaccination, particularly in the context of the NHS's new vaccination strategy, which came out at the end of December, shaping the future for NHS vaccination services. So Steve, welcome to Health On The Line.

Steve Russell

Thank you Matt, it's lovely to be with you.

Matthew Taylor

So there'll be some people who will listen to this who know a lot about vaccination, but I suspect quite a lot of people who don't really know much at all. So just to start off getting into this, just tell us how the vaccination system works now. Who provides vaccinations?

Steve Russell

Yeah, I think I know more about this now than I anticipated, as you say, Matthew. So probably the first thing to say is something that I have reflected on and learned working with you and colleagues in ICBs and wider systems. Vaccination is one of the most effective public health interventions and it's most effective second only to clean water, which kind of just sort of sets the frame of how important the range of programmes in England, and across the world actually, are in terms of improving people's protection against ill health. And we're really lucky in the UK and in England to have really quite robust and well-developed vaccine programmes already. They've been in place for many, many years, have developed and grown and changed over the years.

In England, to your point about how does it work now, there are a set of vaccination programmes that are delivered in general practice. Many children, just shortly after they're born, end up having their childhood vaccinations. They're delivered in schools as they become teenagers and go through the school system. They're delivered in universities as people move into university education. 

There are a range of other settings that we've started to use more recently. So a huge, huge emphasis on community pharmacies that are really trusted and in local communities. And then I think a big change occurred in the way that vaccination was delivered in England, and actually probably across the world, through the COVID pandemic. When the model for those delivery settings were both available, but probably insufficient. And so vaccination was taken out on the street, as it were. So they were, We started vaccinating in places that had never really been used before. So churches, mosques, restaurants, barbershops, pop-ups in town centres. 

So in places that people recognised, where they trusted, where they went for other activities as part of their daily lives. And so that has been a huge change in the way that we've started to approach vaccination and wider public health. And that's kind of how the strategy sees the future kind of continuing to develop and grow. 

So that's, that's kind of how it works at the moment. And again, there's 16 diseases that are actually really quite unpleasant diseases that can be protected against through vaccination in those different settings and at different parts of our lives.

Matthew Taylor

And the position that we're in is that we know how powerful vaccination is. We know how effective, cost effective it is. And we have the success of the covid vaccine, but actually vaccination rates have been falling, haven't they?

Steve Russell

They have, particularly in childhood vaccinations. England has relatively high uptake of vaccinations across all of the programmes compared to other countries, although some other countries do have higher uptake. But you're right, Matthew, particularly childhood immunisations have declined over the last ten years. And we're concerned about that. And we've seen outbreaks of measles, which is a very, very unpleasant illness for children in particular. 

We've seen outbreaks in both London, there's one at the moment in the West Midlands, and it is a very unpleasant disease, it's very serious, but can be protected against with a set of vaccines. And so part of the strategy is about improving access online, making it much more convenient, but it's also about really strengthening the community-based offer for vaccination in places that people trust. 

So improving on and building out from the locations that we currently use. I think what we've learned from the covid pandemic is it's not sufficient just to say here is a location in which you can have your vaccination come to us as it were. 

People want to understand more about what vaccination means, they want to understand the benefits, they want to understand a bit about the risks, even though vaccines are very, very safe and very well tested. And you can look at lots of different places.

Manchester is a really good example; Trafford, school aged immunisation services noticed that they didn't have as high uptake for children as they would like. And they made contact with parents to try and encourage them to bring their children forward for vaccination. And as part of those conversations, what they learned from parents was that they wanted more information. They were a bit hesitant.

And so they organised a set of parents' evenings in effect where people could get information, be talked through the benefits and be talked through the benefits by people they trusted. And as a consequence of that, they then ran some vaccination clinics and were able to vaccinate a relatively large number of children who had not previously come forward. 

So it's really trying to tailor it to what people feel is important to them. One of the things we learned through the pandemic was, towards the end of the pandemic, was it wasn't enough to just talk about vaccination. People wanted to talk about other issues. So, many of the kind of local pop-ups that are run at the moment, that again, the strategy sees as a really important way forward, aren't just about vaccination. 

They're about health and wellbeing, mental health, benefits, advice, topics that are in trust to the local community. So we learned that one community was really interested in perinatal mental health. And so there was a set of kind of health days set up around that of which vaccination was a part, but it wasn't the primary thing. So really setting it in a kind of broader prevention space, which is something that ICSs is we think and I know you think, are really well placed to take forward.

Matthew Taylor

One other bit of context before we get more into the kind of strategy, Steve, is we have the HPV vaccine, but I think it's widely thought that there will be more vaccines in future covering a wider range of diseases, particularly there's a lot of excitement about the potential for other cancer-related vaccines. Now, that's not something I think that's directly central to the strategy, but It could be this question of how it is we deliver vaccines, how we encourage the public to take up vaccines could play an even more significant role in the future, couldn't it?

Steve Russell

Yeah, and I mean HPV is a brilliant example - you might think about HPV vaccine in a certain way, but when you frame it in what it could achieve, to your point, one of the ways to eliminate cervical cancer is through increasing HPV vaccination rates. And it is a real possibility, and we have said we intend to, partly through the strategy, aim to eliminate cervical cancer in England in the future through improving vaccination rates and through improving screening. 

And that is like a goal worth going after. And you're right, technology has changed, science has changed over the years. The new cancer vaccines, like the personalised cancer vaccines that are being talked about, researched and developed, they're incredibly exciting.

There's currently discussions going on about the RSV vaccine, which could potentially really help protect children from respiratory virus and older people. And actually the evidence in the US is that it could potentially reduce admissions for children by 80 per cent in the RSV season. And again, that is, when you talk to clinical colleagues about what they see in pediatric intensive care when children get serious illness as a consequence of RSV, again, that is something really worth going after. 

So the opportunity to really impact on health gain, health protection, population health is absolutely within grasp.

Matthew Taylor

Yeah, and this is something that we mentioned before, but I just want to really underline it. The cost effectiveness of vaccine intervention is really startling, isn't it? One of the things, Steve, that I get impatient about sometimes is that talking to colleagues and leaders, we talk about prevention in very general terms but we're describing when we talk about prevention, we're describing an immense array of different kinds of interventions. And, and I think that one of the challenges we talk about prevention is to be really clear about, where the low hanging fruit is, where the really obvious things that demonstrably save money and improve people's lives, where they are. 

And as you say, vaccination ticks all the boxes. And that's why I think when you look at the case for vaccination, both financial case and case in terms of improving people's health, when you look at the potential that vaccination might have in the future, but you then look at the fact that still in some domains we've got falling levels of vaccination, particularly amongst children, then this really is and should be a national priority. 

You know, it's really important the strategy has come out but in a sense, I sometimes think in the kind of public discourse that even after the strategy, we just don't talk about this enough. There is this in public policy, I spent my life in public policy. In public policy, there are very rarely things which tick every bloody box, but this one does.

Steve Russell

Yeah, absolutely. And I think you are absolutely right. This is not as dominant or present in the discussion as it could or should be, arguably. And I think that's why, so I think there is, as you say, there is absolutely an opportunity for both the NHS, but actually working with partners on this, because there's a really important piece about education so that people understand the benefits of vaccination much earlier and in a much more deep and meaningful way than perhaps has been in the past. 

I think there's a really important role for government. I think there's a really important role for education and that's one of the things that excites us about delegating vaccination responsibilities to integrated care systems because those are partnerships of local government, the NHS, the voluntary sector, and many others, all of whom really care about these issues, understand local communities, have roots into local communities that trust them and can help, I think, to your point, raise awareness of the benefits, but also build trust and confidence. 

We talk about in vaccination, the three Cs, one of which is confidence and one of which is complacency. And building trust, building confidence and reducing complacency is something that is really critical. And the vaccine strategy won't achieve that on its own without all of those other partners.

Matthew Taylor

One of the things I find fascinating about this conversation, Steve, is the way in which the question of vaccination takes you into some, some deeper issues around the whole way in which we think about health and health policy. Now, I want to get into those in a second. But let's just focus on the strategy, because I do want to give you an opportunity. But what do you see the strategy as making a qualitative difference to in terms of the success of our vaccination programme? 

What in essence is it when you signed off that strategy where you felt these elements of the strategy are really going to make a difference to our performance?

Steve Russell

So really, really good question. I think there are three central points. One is that we want to see increased access and increased personal control in many ways. So, improved access through our online platform, the National Booking Service and the NHS app, being able to see your vaccination history, know what you are eligible for, and be able to just book it kind of at the click of a button. That's thing one.

Thing two is vaccination being offered in community-based settings, in convenient places that people trust, and vaccination being delivered by people that look like the communities we are trying to serve better than we've historically done. 

And the third, is joining up vaccination with broader prevention and public health offers, whether that's blood pressure checks, education about mental health, social prescribing, benefit advice, welfare checks, all of that work that integrated neighbourhood teams are kind of designed to do. 

So those are the three things that I think we hope that the strategy will achieve and that will mean better coverage, better protection, more people protected against serious disease and actually a wider economic benefit as a consequence of that.

Matthew Taylor

So I want to get on in a few minutes to the challenge for ICSs of delivering this, because it is an exciting responsibility. It's the kind of thing ICSs want to do, but it comes at a time when they are very challenged by all sorts of other things. But what I want to explore, Steve, is three ways in which I think the question of vaccination takes us into a broader conversation about the way in which we approach health policy. 

So the first is I think if I was Prime Minister tomorrow, I would see vaccination as something that I wanted to be a priority for the government as a whole, not just for NHS England or Department of Health or ICSs, but I'd want to be saying to my Education Secretary of State, to my Business Secretary of State, to the whole Cabinet, look there aren't many no-brainers in public policy, but this is one and I want us to set a very ambitious target for the country. 

So the strategy is really impressive, but in a sense, does this link into something which many of us have called for? It's going to be part of the NHS Confederation's own manifesto before the election, which is the need to try to think about health policy in a more cross-Whitehall way that we do really need to mobilise the whole of government, not just health in this area?

Steve Russell

The short answer to that is yes, definitely. The evidence from the covid pandemic really supports that argument. It was an incredibly successful programme, but it could not have been delivered and it could not have achieved what it did without local government, DfE, the Department for Education, the voluntary and community and social enterprise sector. And that absolutely requires joined-up prioritisation alignment across government. And not just in central government but in local areas as well. I mean, I'm biased, right? But I agree that this is a no-brainer. 

It's the same for screening. Screening is a no-brainer in the space of prevention and improving population health. Life has moved on, obviously, but I think in the last sort of official manifesto, the government did commit to, in effect, a version of a vaccination strategy. Now, the NHS has published its part, which is how the NHS would deliver in concert with partners, but I would very much hope that government will return to the commitment made previously around a broader cross-government piece to support vaccination and actually screening and other public health interventions.

Matthew Taylor

It's timely actually that you should say that Steve, because the Department of Health has agreed now and we’ve been pressing for some time to take forward the Hewitt review recommendation of a national forum in which ICP, ICB chairs can engage with the whole of government. And I think this would be a really good topic for us to put because we'll be I think working with the department being kind of a secretariat for that forum. This would be a really good topic to put on the agenda for that. 

So that's great. So that's one kind of element, which is that the vaccine issue relates to this broader question of how you acknowledge the need to mobilise the whole of government in relation to some key elements of improvement, improving the nation's health. 

The second is the way we think about our interactions with people because of the focus we have on the acute sector and because of waiting lists. I think we have in our minds that the problem of health is that the public want more from us than we have got to offer and that the fundamental challenge for health is about the rationing. So we see health, we see the challenge of health, the day-to-day challenge of health as there's this kind of unlimited demand in the community and somehow we've got to deal with this and channel it and ration it. But actually…

Steve Russell 

It’s the opposite.

Matthew Taylor 

… it's the reverse. Actually, what we need to be doing is not reducing people's access to health, but increasing people's access to health. And you'll talk in a moment when I finish this incredibly long question about what that means vaccination. But I see great examples, actually - I was just chatting to a leader the other day about a GP who just goes out and has whole day open days and invites the public in to groups of the public or around a particular condition.

Rather than a situation where you've got to wait for a GP appointment, wait for a consultant, go back to the GP. The whole thing happens in a day. People are checked out if they need to see someone, it's there and then they can be dealt with. And it's incredibly effective. So it seems to me vaccination also links into this question of how do we get out of the mindset that our problem is the public want too much and get into a mindset that says, actually, if we lent into the public, we'd actually be much more effective.

Steve Russell

Yeah. That is one of the really exciting opportunities, both for vaccination and as you say, more broadly. So, we want to vaccinate more people. Exactly as you say, we do not want to manage demand down. We want to increase it because, to your earlier point, it is one of the most cost-effective things to do for people. 

It isn't the case that we will achieve that by just saying, please come to us and then we will offer you a vaccination when you come to us. It needs to be, that's an offer that will continue to be present through general practice community pharmacy, but to really improve coverage, address health needs it needs to be in places that people trust and actually it needs to be packaged in the context of what's important to local communities because it's different in different places. What is important to the local community in north east London is very different to what's important to communities in Bristol or in the north east of England. 

There's a GP in north east London who you will know, who has basically just taken the attitude of I am going to get a load of people to support going into places, into the community and offering access. So access to primary care, access to health advice, access to vaccination, access to things that are important to the local community. 

I remember somebody saying people have been talking to me about the importance of getting a vaccination. I can't afford to heat my home at the moment. So that is not my priority. So again trying to speak to people and speak to people's priorities and setting all of those public health interventions in that context is one, really important and two, it's really effective.

Every time you see communities run pop-up roving events with all of that breadth of activity, there's loads of people that go. And we sometimes often think that, oh, the thing to do is to build a fancy building that looks like an NHS building or whatever. That's not what people need or want. They want it to be in a place that they recognise in the local community they visit for different reasons. 

And so I think like it's an increased version of Health on the High Street. And I think ICSs will really, really get into some interesting spaces over the coming years. Our experience is people are really up for this. And it's an area that they care passionately about.

Matthew Taylor

Yeah, I think this is so interesting because I think that the public, because we read constantly about waiting lists and how difficult can be to access GP services, dentistry, etc. that we just have it in our minds that when the NHS talks about us doing something that it's going to involve hassle and waiting and all. 

This is a terrible admission given my own role. You know, I'm in York and the local chemist had a thing in the window saying get your flu vaccination here. And I know that my immediate thought was, oh god, I have to go in, I have to book it, it'll be, you know, I just, I couldn't really compute the idea that this was, that this might be. I didn't actually know how they did it in the end because I did, I did book it. I did get it done. 

Steve Russell

Good, I'm glad.

Matthew Taylor

But you kind of think, oh god, it's the NHS, it's going to be hassle, it's going to be difficult. That's, I'm afraid we've been en-cultured into that view. And so to get people to know that's not what this is like. This is much more like a business is trying to get you to buy something that's leaning into you, that really wants you to do it, that will be delighted when you contact them. 

But there's a third element of the vaccine conversation that I think links into a broader conversation. 

What we talk about in the Confed is a social contract with the public because if you don't get vaccinated, it's a problem for you, but it isn't just a problem for you, particularly when it comes to infectious diseases. And it isn't just a problem for you because in the end, if you get sick, the tax-funded health service is going to have to help you.

Do you think that we need to be willing to be a bit more assertive about vaccination as a public responsibility, as a duty of good citizenship?

Steve Russell

That's a very big question. I think the central thrust of that is right, but I think the route to get there is worthy of really careful consideration. When we were doing the strategy, we tried to learn from around the world, and there are countries where it culturally is seen as part of your duty, as it were, and they do have higher uptake rates. 

There are some places where you are required to be vaccinated to a certain extent in order to go to school. And those countries have had that in place for a long time. I think one of the things that has really struck me Matthew in some of the vaccine conversations, I remember this from when I was at Harrogate and when we started to offer vaccination to colleagues at the trust and also more broadly in the community - people who people who, where coverage is lower, we often describe them as less well-served communities. You really need to lead into the confidence piece or the trust piece. 

I remember somebody saying to me, she was a paediatric nurse, she said, look, I spend my life looking after sick children - reminding people of the benefits of vaccination when it is appropriate to do so. She said, but when the vaccination for covid came out, she said, I waited until I was prioritised because I was from an ethnic minority. So I was prioritised because I was at higher risk. She said, I waited until my white colleagues had the vaccine because I've never been offered anything first in my life. 

And that sort of conversation has been repeated time and time over in different circumstances where saying to people you need to do this because the authority thinks it's a good thing to do.

That message works for some communities, but it absolutely, it definitely doesn't work for all. And so I think the thrust of your point is right, but it's then how you achieve improving trust and confidence. And that is what that is often, again, our learning is the NHS is a trusted partner to an extent, but not everybody trusts the NHS, because in some circumstances it is still seen as the an authority. 

And so that is where the voluntary community and social enterprise sector in particular has been completely critical to building confidence in communities where there's not necessarily that trust between the community and sort of authority. 

And that needs development, it needs investment. We need to recognise its importance because those are often organisations that connect in and have the confidence of very, very different communities from different backgrounds. So yes and the route you get there is just super important.

Matthew Taylor

And I get that. We're talking in a week when there's been debate around Keir Starmer talking about, well, I don't mind being seen as a nanny state if it's kind of good for people. And to be honest, I just think we should be more imaginative. Why don't we say to the major supermarkets at Christmas time, could you give people a five pound food voucher if they have a flu vaccination? And you'll get customers in at Christmas, which is when you want customers most in, and obviously people on lower incomes, that five quid is going to be more important to them. 

You don't solve complex policy problems with a single thing. So yes, it's reaching out to communities and winning trust, but yes, it can also be really simple financial incentives and et cetera, and also the technology element of it. And that, of course, that's why you have your strategy. 

Now, I could talk all day, but let's close the conversation by getting into the question of delivery. And vaccination is like so many areas for me in relation to health service, which I get terribly excited by and I'm really excited about what the Confed can do to support the work that NHS England or the department is doing. And then someone tries to explain to me the process of commissioning and the complexity of the different roles that people have. 

And my eyes glaze over and I think, oh my God, it's just too difficult to understand. Now, the fundamental thing that's happening here is that ICSs are taking responsibility for the delivery of the vaccination strategy. But what are the delivery challenges and particularly, and you and I meet every few weeks to talk about ICSs in general, what concerns have you got about the capacity of ICSs to be able to deliver?

As you say, they really want to but these are organisations that have had to make a 30 per cent reduction in their running costs - they're dealing with an incredibly challenging financial situation. They're still quite fledgling organisations.

Steve Russell

Yeah, I think that's a very fair point. I mean, the most encouraging thing I think through the development of the strategy and actually through visiting all of the ICSs in England, and I always take the opportunity to chat about vaccination and screening as you would expect. The thing that I think is really encouraging is, as you say, people really people really want to do this. It's something that's important to them. 

There's not a, oh, here's another task that we've been given. People have been incredibly engaged from integrated care boards, integrated care systems, local government, VCSE, and the development of the strategy. So I hope that it sort of speaks to what people have said they think is important, what they think will work, and what they want to do, and what they want to see as their contribution, as it were. 

I think your point is really valid. The breadth of stuff ICBs, ICSs have to do is huge and it's not like a really easy territory. What I feel about it is, all of those are the things that you mentioned there, they're important, they are absolutely really important, they'll continue to be really important. I've seen people get really excited about this work and actually not vaccination on its own, but in the context of broader prevention and population health. 

I think there's joy in doing some of this, and particularly in both the design of a network and the design of some of the community settings. And also, you don't solve some of these things nationally, it is about knowing your local community, what's important to them, and then thinking about all the different things that you can do to meet their needs in this context. 

So I think people generally draw lots of energy from this sort of work and want to get into the prevention space and I think the task in hand for us at NHS England, supported and emphasised and amplified by the conflict, because you are brilliant at doing this, is keeping this on the agenda.

What people talk about gets focused on. And so keeping the service discussion evenly balanced across prevention, constitutional standards, value for money and so on and so forth, I think is a really important role to continue to play. The commissioning arrangements, as you say, they are complicated. We're going to simplify them.

And the reason that we think ICBs should take on the responsibility is vaccination is about population health, screening is about population health. That is what ICBs, ICSs are all about. They know their communities. We will give them the resources and hopefully some tools to design a network that works for their local community. And the financial framework is also a bit complicated. So we're going to look at how we develop the financial framework to particularly support some of the outreach work over this year.

Matthew Taylor

At the heart of the strategy is this notion of vaccine delivery networks, but you're quite indeterminate about what these should be. You want vaccine delivery networks that will look different in different places, but it's critical to have a lead person who's responsible for the vaccine strategy and to have a vaccine delivery network. Those are the things that are mission critical from your perspective?

Steve Russell

Yes, and I think the absolutely the wrong thing to do is to say this is what a good vaccine delivery network looks like because it needs, as you say, to be tailored to local areas. What works for people who are resident on boats in the south west is going to be really different to what works for the community in Hackney; it's going to be really different to what works for the homeless community in Cheshire and Merseyside. 

And what we've seen is local areas designing just really simple ways of taking vaccines and public health interventions to people in places they trust. So we say there should be a consistent offer, front door offer through general practice, community pharmacy, and then that should be supplemented by what we've called ‘outreach’, which is not necessarily the right term, but is what we've used to describe the sort of things we've been talking about. And that must and should be decided upon and designed by people who know their local community.

Matthew Taylor

So I completely agree with that, Steve. And as someone who, as you know, is a champion of devolving to systems to places. But I also think that data is important because I think that the corollary of saying to people, you can do it in the way that works for you, is also to say, we will be publishing data that will be really clear about how well you're doing and where if you're not doing very well, you can't hide away. So, I probably ought to know the answer, Steve, but how strong is the national data here and how much part of the strategy is going to be regularly kind of holding up a mirror to the system across England so that places that are lagging behind, either in terms of the level of coverage, but also in terms of penetration into particular harder to reach communities. Is that an important part of it, do you think, that accountability?

Steve Russell

So both the accountability, responsibility, and the data are absolutely critical. And to the first point, that is exactly the point around your point, ICBs will be responsible for this. And rightly, we need to make sure people have got the resources and tools to deliver it. So part of the strategy is effectively to extend some of the data capabilities that we have for covid to all of the other vaccine programmes.

So in the covid programme, we and ICBs can see in pretty much real time what coverage looks like for different communities, different population groups, different cohorts of people. You can see it by street level. ICSs use that data to understand where there are where there are people who haven't yet been vaccinated and can do really hyperlocal interventions to try and offer vaccination. 

There's a brilliant example in Liverpool. They spotted a group of streets where vaccination rates were very, very low. And they had like a two-week model. So week one, one of the district nurses would go and knock on their door and talk to them about how they were, not necessarily about vaccines but just how they were. And then week two a vaccinator knocked on the door and offered people vaccinations. So we don't have that for the other vaccine programmes. We currently get very high level sort of what's the coverage like in a geographic area. So part of the strategy is rolling out national data capabilities for all programmes that then ICSs can use and can use consistently.

Matthew Taylor

Well, Steve, it's been, you know, absolutely fascinating conversation. I was already a vaccine champion, but I feel like I've become a vaccine zealot as a consequence of talking to you. Thanks so much for the work that you've done on the vaccine and thanks for joining us on Health On The Line.

Steve Russell

Thanks, Matthew, lovely to see you.