Forget What You Think You Know about...the vaccination roll out

Paulette Hamilton: Hello and welcome to the ‘Forget What You Think You Know’ podcast.

I'm Paulette Hamilton, I’m the cabinet member for adult social care and health in Birmingham. Something I really do enjoy doing is my initial role as a local councillor in the Holyhead ward in Birmingham City Council.

On today's episode I'm joined by Jim McManus director of public health at Hertfordshire County Council, Julie Yates the lead consultant for screening and immunisation at Public Health England and Eleanor Kelly the chief executive of Southwark Council and national adviser on vaccinations.

Today the panel and I will be discussing the role out of the vaccination programme, the important role of the NHS, councils and local partners and how collectively we can keep up the fight against covid. We will also be looking at some of the contentious issues about vaccinations like vaccine hesitancy and health inequalities, and how we as local champions can come together to address them.

So without further a do lets get to it.  

Jim McManus: So my name’s Jim MacManus and I’m director for public health for Hertfordshire as Paulette said, I'm vice president of the Association of directors of public health and I'm a chartered psychologist by background as well, as someone who's worked in public health for many years. at worst the vaccine performs a bit like a seat belt it may not stop you having an accident, but it will stop you dying. At best the vaccine will stop transmission. But it's not the only tool in the box we still have to do prevention and everything else so all the physical distancing and hygiene measures we will still need to keep on with.



The second key thing about vaccines is that viruses produce variants - that's just normal and when you’re rolling out a vaccine at the same time that the virus is circulating that's a dangerous time to get new variants that can evade the vaccine. So the things we have to do there are firstly get maximum uptake of the vaccine and secondly get maximum prevention, so things like self-isolation and testing and prevention become more important than ever.  

the vaccines will be a part of our strategy going forward, but we need to give the vaccine a helping hand. Is that a fair summary?

Paulette Hamilton:

Julie, I want you to try and beat that. If you could just give us a bit of an introduction, I would really appreciate it.

Julie Yates: Well it's quite hard to top what Jim has already said, but I agree completely   

I think it's important to recognise that we have built this vaccination programme on the back of all the knowledge and experience that we have of our very successful population vaccination programmes in the UK, so that we have very effective means of giving vaccines, of making sure that they are safe, we've got the structures behind this and we've got all the organisations and expertise in our directors of public health, in our health service and also in the wider NHS and community structures to be able to deliver this in a very very effective way.

I think some of that is important in actually building the confidence that we need in the population, particularly when we are bringing in vaccines at pace and it's at speed because there will be some concerns about whether corners have been cut but building it on the back of what we already know means that we don't we've got the structures there

Paulette Hamilton: That's fantastic Julie, fantastic. Can I go swiftly on to Eleanor, Eleanor Kelly.  If you could give us an introduction please.

Eleanor Kelly: Thank you Paulette. I'm Eleanor Kelly I'm the chief executive of the London borough of Southwark and I'm currently seconded into the vaccination programme as the local authority chief executive national adviser which whic h gives local government a voice within the programme and from the programme. I’d just like to put what both Jim and Julie have said into context.  

As of today we have delivered 22.7 million vaccinations of which 21.4 are first vaccinations and 1.2 are second vaccinations and that 1.2 will really rapidly rise now that we're past the sort of 8-9 and ten weeks of people receiving their first doses, so the vaccination programme has been progressing at pace. That achievement doesn't belong to the programme - it belongs to tens of thousands of frontline NHS and local government staff. It belongs to volunteers, it belongs to staff like transport workers, warehouse operatives, delivery drivers and many more all who have played in the most amazing part to ensure particularly that those most at risk groups have now been offered the lifesaving vaccination.

I think everyone involved across the NHS, across local government and across our community should be incredibly proud and so then it really has been a team effort and I'm pleased to see that governments and others recognise that and all of the praise and thanks doesn't actually just go to one sector, it goes across the piece.

moving forward we really are sort of like focusing on the three factors identified by the World Health Organisation which are confidence which is actually about vaccine hesitancy and confidence in the vaccine as Julie said.  Convenience which is about removing barriers to access and complacency which is about understanding the reasons for complacency in relation to not having the vaccine which we think will continue to be and will rise as we move through to the younger and cohorts. So that's what I would like to say by way of introduction, thank you very much.

Paulette Hamilton: Can I say to all three of you well done, but now I'm going to be awkward because I will be breaking down some of those broad-brush statements so we can get some really intimate information. we've got to live with COVID-19 in the future - what do you feel of the things we've gotta do what a local level to ensure we can maintain the vaccine roll out? Now I'm going to start with Eleanor on that one.

Eleanor Kelly: Thank you. The answer really is about getting hyper local and it's really sort of like addressing what needs to be done in a way that communities will respond to.  And for the most part that will be designed and led by the communities, because that's where their trusted voices will be and that's who they will listen to and that's who will really sort of genuine genuinely understand what the real barriers are  within those within those specific communities.

There's fantastic examples all over the country and we’re involved in actually capturing those and being able to replicate those that show other people with similar demographics what's worked in other areas and be able to really sort of like understand what would work in each individual area, really sort of like down to whether or not a particular sort of communities would like to sort of takeover and run, and apparently run, is what I would sort of like say vaccination centres.

A fantastic example in the South West where vaccination activity within a mosque to all intents and purposes is run by and for the community.  In actual fact it is part of the national programme but that doesn't actually matter that's what that's what helps to get the vaccine there, that's what helps to get vaccinators there. But to all intents and purposes it is a very very locally run and therefore trusted way of getting vaccinations. There’s some funding being recently sort of like being pushed out into the NHS with a very sort of like clear instruction that the best way of getting the best outcomes would be to work with local authorities and community groups and that's sort of like, effectively like the seed funding. The more that we can like see what works then we can go back and get some more money from the national pot to roll out that out to others.

Now I could give some of my specific examples but for anyone whether it's an employer whether it's it's in a community organisation, whether it's going to a particular community and any part of the country and whether it's a particular religion anything that sort of almost as an interest group - that's how you can sort of like really capture and get people to listen to you and be able then to design the delivery models around that that will mean that you will get the uptake.

And listening is absolutely vital having that feedback and having that feedback loop not just to capture best practise or what's worked well but to listen to concerns and where we have listened and I think the programme really has listened and where we have listened to concerns would be able to self like get ahead of issues for example people without any NHS number or homelessness or the concerns coming up in relation to two Ramadan.

So what I would sort of like say is we're listening but people need to be talking you need to be sort of like feeding into us you need to be making your voices heard in a positive way it's not about some complaining is about pointing it up we won't defend the indefensible we can't defend the unknown we need to know so that we can get one step ahead and really start addressing these issues in a way that will make communities overcome their hesitancy, feel confident and and and and not be complacent and really sort of like move forward to get their jabs as soon as they're in the cohort.

Paulette Hamilton: Right thank you for that. Jim I'm going to ask you have you got anything to say re Hertfordshire

Jim McManus: Well I think I’d agree with everything you and Eleanor have just said. from our experience there are three golden rules and four big pillars. And the three golden rules are - living with cool it means everybody knows what skills they need to live work study operate safely in an environment where COVID is still circulating that's the first rule.

The second rule is everybody needs to be confident that they can help the vaccine so we need to move from vaccine hesitancy to vaccine confidence that's the big goal and then that brings in your dressed up by the big four and the big four are structural barriers so you've addressed some structural barriers in what you both been talking about so can you get to the centre is it culturally acceptable are the lists accurate what about people who are not registered with GPS so we've got a big GP campaign going on locally the next thing is hesitancy which is a technical psychological term for the fact that people understandably have questions about the vaccine for multiple cultural ethical and scientific reasons.

The third thing is data so we now monitor optic by age and ethnicity in different bits of the County so we can tell where the gaps are and of course one of our gaps is in our Eastern European population who are all manual workers none of whom are registered by GPs well that's easy to solve. It’s a different problem from you know the fact that staff who have cultural memories about racist actions by doctors have understandably different questions so you have to take each population on its merits and address their issues honestly and upfront and I think local authorities are better at doing that to be honest.

Then the final thing is the disinformation don't spend all your effort combating  disinformation just pump out accurate information and build confidence cos all the evidence says that you’ll do a better job that way, so I think local authorities on the structural barriers, the hesitancy the data and the disinformation give them the tools and they will do the work and that's what I would say after what 30 years experience in public health. (31.37)

Paulette Hamilton: we know that there is hesitancy and we know we want to build up confidence - so how can local government help the NHS to address the issues of vaccine hesitancy as a key challenge throughout 2021?

Julie Yates: I think Jim’s touched on some of it already and one of the key issues that arises when you - the most important thing in all of this is listening and listening to populations and not making assumptions and not treating everybody as the same it's very easy to think that one approach will work for everyone.

I'm different than other colleagues on the on the call, I'm different from my next door neighbour I'm different we don't all have the same questions we don't all have the same concerns but there will be many many factors that are underpinning my beliefs and my understanding and my confidence in the programme and it's really important that we do have it considered at very local level because one of the ways that you can build confidence is actually by conversations and it it sometimes comes down to individual conversations with small groups or and and by trusted individuals so listening is one important factor but trust is another key factor, so it is important that people are able to have the correct information but that also individuals, groups, parts of the communities can have those conversations with people that they trust that they respect that they believe and understand where each other are coming from on it.

And those are the key messages that have come back from conversations with groups and communities that we’re having on the ground, so I think that those two principles are so important. Alongside that making sure that those trusted individuals have the tools, the information, the resources to actually get those messages across is really important and so local authorities have a key role in this because local authorities and particularly directors of public health and their teams understand and know their populations intimately.

They know where those populations are they know the trusted individuals and they have the contacts of people who can advocate, who are champions for those communities and they know the right way at the right times and the right places to actually go to talk to and meet those people in a way that is appropriate for them culturally, socially and every other way so it's really important that we have that joint collaborative working between the NHS and our local authority and other wider stakeholder partners.

Paulette Hamilton: I'm gonna handover to you Eleanor because I know you do this on a national level and this is the sort of granular things that we're dealing with on the ground.

Eleanor Kelly: Thank you Paulette and Julie I think absolutely sort of like nailed it in relation to her answer to your earlier question and that the important thing for local authorities in respect to that is actually being about really being that showing true local leadership and getting those messages across and sort of like doing all of those things that that Julie said.

In relation to the question that you're asking about being able to sort of let roll out getting those individuals answers to people and that sort of like getting that trusted voice in a national sense - the nhs has come together with the local government associations with the government departments including the MHCLG, DHSC and DCMS to develop and share messaging with local authorities to ensure that it’s a really seamless, joined up and unified voice.

What you don't want to hear is to hear one answer from one place and another answer from somewhere else it's too important we've actually got to get those particularly those health messaging about things like fertility to get those right and there's toolkits including key messaging, messaging for social care workforce, for carers and tools that support tackling the sort of information that you're talking about and on WhatsApp and social media and that being developed across all of the sectors.

So I think what that does is actually be able to put a resource in everybody's hands so that they can use but that they tailor it to what they know either about the individual, or about the communities because what Julie said about local authorities knowing their communities, knowing the issues that will be important to them, knowing how to find them, knowing how to reach them, knowing how to talk to them is absolutely vital but we want to make sure that we sort of like use our resources wisely

Paulette Hamilton:  Brilliant Eleanor and Eleanor I'm going to ask you one other question at this point how do we make sure everyone has equal access to the vaccine?

Eleanor Kelly: I think the issue of accessibility is an important one because it is actually sort of like goes to the heart of that hesitancy because if you make vaccine available and people don't come forward there’s evert danger that you just move on to the next cohort and that's not what the programme is doing at all.  

I think there are other issues that both Jim and Julie are in a better position from a health perspective to be able to answer - but from a logistical perspective making sure that the vaccine is available for all of the cohorts and to be able to take them up in in in order and not allow areas that for whatever reason could really sort of like rush through and get everybody vaccinated just because they don't have hesitancy or just because they don't have barriers and would actually be unfair and unequitable and we are very very conscious of that within the programme.

Paulette Hamilton: Julie could I ask you do you want to add any points to that?

Julie Yates: What I would add to that is that access is an issue and quite often when we seeing lower uptake in groups there's an assumption that its hesitancy when actually it's it's more of a practical, structural, reasonable or a factor associated with the individual.

They might have large families they might not have access to transport lots of different factors come in so we need to look at this in the round but one of the things that I would say is that we also need to remember that this is not the only programme that we have a lot of experience from other programmes - from the screening programmes, from the immunisation programmes we’ve got 23 vaccine preventable diseases.

We've got a lot of previous experience and knowledge and understanding from Jim's behavioural insights through to our NICE guidance on improving access in other immunisation programmes, so we need to build on all of this knowledge and experience and make sure that we don't forget what we already know.

We need to apply all of those including bespoke models for delivery, taking the vaccines out to people, making sure that they are delivered in a place that they can both access but they can also feel comfortable in receiving them in so there are many many things that we need to consider, but again our local authority colleagues are partnered with us in delivering those other immunisation programmes and also in the screening programme so this is something that we do as is normal practise we just need to ensure that it's all built into and remembered when we’re delivering this particular programme.

Paulette Hamilton: That's fantastic Julie. Jim do you want round that off because that just gives us a full picture.

Jim McManus: I think there's two important lessons that will come out of this, because Eleanor has talked about multiple capabilities in local government and Julie has talked about the multiple capabilities of the public health family you know PHE and other have.

So, the first lesson that will come out of this is that we kind of forgot that that public health expertise was there in the early role out of this. You know at the national level I mean I saw comms coming out from national that I just thought  ou know that people like Julie and people in my area have forgotten more about vaccine in screening uptake than than most of us will ever know and and it's crucial that we use that expertise which is psychological, public health, medical and scientific on uptake and and we failed to use that at our peril for uptake because the disinformation and the myths will fill the vaccine.

The other second massive lesson is that local government has brought a team of teams approach. So you've got public health plus logistics plus elected member leadership plus social care plus plus.. I could go on all day and those have been really neatly encapsulated in a series of case studies on the LGA website on vaccination case studies and for me those are the two big lessons that the technical expertise has been there for years and the new abilities of local government to get their heads round this in a way that actually we haven't seen in vaccination programmes historically. Those two together can only bode well for the health of the population.

Julie Yates: Yeah I think Jim is is right that we've learned an awful lot from the programme. We’ve recognised what we already had and brought that into the programme we've been able to build on that we've got better collaboration, I think we've got some really really good developments in data that we haven't had for other programmes and we although that took a little time it's now we got equality's tools we’re able to drill down.

If we can build that into our other population health programmes then that is a massive opportunity to support our populations going forward so yes there's been a lot of challenges but I think building that technical expertise the teams and teams approach and all of the other structural changes and support that we've had around this programme into others then that's it that is a really big opportunity to build better and and we want to build better as a result of the COVID pandemic that's one of our general aims.

Paulette Hamilton: how do we engage with communities, particularly the underserved population such as rough sleepers, people who are homeless and for them to take up the vaccine because those are specific groups that sometimes if we're not careful we do miss them -so can I go back to you as a start point please Julie?

Julie Yates: Yes, I mean I will come back to the listening and trust principles to start with we need to understand where the populations are and how we can get to them who they trusted etc as we mentioned before and I think as part of answering this I'd like to give an example of where I’ve see this work really well and that's in one of our towns in the South West down in Plymouth.

What happened there was that the local authority worked with colleagues from MHCLG, with all our LRF partners, our health partners and actually brought together a specific session for our homeless population within reach of a centre.

They created a bespoke specific vaccination session or sessions for this population they wrapped around that the GP service to be able to do additional health cheques, they brought in the street vet they brought in people to provide food and other services, so a whole wrap around approach enabling individuals to feel comfortable with people that they knew advocacy services they knew. They put on transport services from the homeless hostels to actually bring people into the service and they vaccinated 263 individuals from the homeless population in their session.  

So that that would be how I think you need to engage at a very very local level with people who understand the services know where the people are and then actually put in all of the elements that you need to be able to facilitate those people coming to the service or or if you can't taking it to them, but also making it worthwhile for them to go to  the service beyond the vaccination, because we know people who are in underserved populations have other health needs as well, so you can maximise the benefit of this programme by piggybacking it onto lots of other things that could be beneficial as well.

Paulette Hamilton: That’s spot on and taking it over to Jim. Jim I am a great believer that sometimes the hesitancy as was highlighted earlier is around the issue of people not being able to access the vaccine, but also is it the right people sharing the message because I had this discussion with a group of people last week that said to me well it doesn't have to be faith leaders or others perhaps we need people more locally but my argument was we have to start somewhere and faith leaders were probably the easiest group to bring together at the beginning of all of this and as we've gone down as Julia has said we've become more granular.

So is there anything you want to add that we could be doing especially with that homeless cohort and people like your Bangladeshi communities your Romany communities that seem to really struggle to engage at the moment Jim over to you.

Jim McManus: So, I think you’re spot on. The first thing is do not be deskilled by this because local government wrote the book on community development and we wrote the book on accessing hard to reach populations. We've got the skills to do it so it's a case of systematically identifying the populations and then systematically work out whether its hesitancy or its structural barriers, and it's never just one it's always both or more and structural barriers are are worse in many reason hesitancy and then just develop a plan as Julie says go hyper local and if you look at the case studies on the LGA website – Sandwell built an army of disinformation counter advocates - brilliant countering hesitancy.

Swindon actually used acceptable venues. You've got examples of Wigan where they actually trial run COVID clinics that were acceptable to different communities.

In Hertfordshire we've systematically identified every rough sleeper in every homeless person and set up special clinics we've also kind of organised transport from Watford borough council for people who can't drive, or can't otherwise get to a vaccine clinic and we're doing significant work with communities around hesitancy so we've got BAME doctors working with BAME social care staff on their hesitancy.



Now it was local government that came up with all of those ideas because we understand community development but they were all a mix of - there was a bit of structural there was a bit hesitancy and there's a bit of you know matching that up with where council capabilities can sort it. We know how to do this.

Eleanor Kelly: What I would add to what Julie and Jim have said is that there are countless examples out there and particularly as we move into phase two we're gonna need targeted work based on specific groups that we identify that need help with access or barriers and that we can learn from that from what people have already done so Jim’s given us a number of examples.

I would point out stuff like Bradford in their young ambassadors there 22 young ambassadors that reached over 1000 young people a week laying the ground about when young people sort of like answering their questions and laying the ground for when young people will need to be taken up and the vaccine.

Huge amounts of work in Dorset and Bath with traveller communities which will be really helpful for other people and Jim had said about what they did in Hertfordshire in relation to homelessness but they also did that in Oldham in wave one. They registered all of their homeless population with GP’s. Just because you didn't do it in wave one doesn't mean that it's too late not to do it now, so we've really got to push out that learning

What I would say is it's not just about building back better we've gotta build back fairer and there are huge huge lessons learned in this about how we can make all of those programmes all of those 23 vaccination programmes that Julie mentioned make that fair for everybody because the communities that are not being reached early in relation to this vaccination programme are the ones that are that were already sort of left behind in those other vaccination programmes and its an ill wind  that blows nobody any good there is fantastic good that can come out of the the effort and the fantastic work that's been done, the learning that’s come out over the course of the last year.

Paulette Hamilton: Fantastic now it's my last question I'm afraid, but I do want to ask this before we round this up. How do we build vaccine confidence in young in the younger cohort and tackle tackle misinformation? The reason I'm asking this is because lots of younger people don't necessarily become very ill, but they're going into families with vulnerable people and they’re the ones then becoming ill so how can we build vaccine confidence in this group which I feel will be the group that we will have to do the most work. So can I start with Eleanor please?

Eleanor Kelly: I think I mentioned about Bradford and how they had sort of like thought earlier on about those young ambassadors and I think that's a really fantastic models for other people to to follow on from.

I think that the messaging around the importance for the whole for the whole community and also the impact that that the pandemic has had on young people and on their education, on their employment prospects means that the messages are there to be given.

That young people are young now but then you know they'll get older and then they'll actually realise the impact that their behaviour and their ability to be able to sort of like join in and move through society in a way that's really really it will be really important to them is absolutely vital, and that learning a lesson young about the importance of health, the importance of wellbeing, the importance of community engagement and the importance of taking your position in relation to society and taking ownership and control of your own health and those of others around you is a really important message in learning for us to be able to take that opportunity to really get that message across to young people.

And for them I don’t think it's about hesitancy it’s more about complacency and we really have got to sort of like work hard collectively, work hard to get that message across to young people about the importance for everybody, for them to sort of like be part of that movement and part of that approach.

Jim McManus: I think we've got 40 years of experience from working HIV that shows us that first of all identify the communities relevant, work with them, use their trusted voices and actually empower them to give the message over. And young people are you know most young people these days have got scientific minds where they can understand this complexity of this stuff and have a better instinct for disinformation than most of us adults.

There are very few things I like out of American public health models but two things I do like - one is the vaccine confident programme that their rolling out in America for healthcare staff and I think we could copy it up for young people here and get young people to lead it. And the second thing is in the US they do trusted voices, so barbers in America actually are the people that young men particularly young black men will listen to actually go through those trusted voices and train them. So again, there there's a lexicon we can use here on this and I think we should start pushing on that.  



if we play our cards right when we come to revaccinate people which we may need to do in this pandemic, or we may need to do for the next pandemic because there will be another one - they're coming every 10 years now these new animal emerging viruses.  We need to learn the sheer capability that local government has harnessed alongside the NHS and all the kind of technical and scientific families and Public Health England and others and among that will be the sheer capabilities of local authorities can improve vaccine uptake and vaccine access. That’s a massive realisation it's a marathon not a sprint so is Eleanor and you said Paulette, start somewhere and work out from there, but start with populations and listening and you know take out the old communities development textbooks from the 1970s and dust them off because the principles work here.

Paulette Hamilton: Thank you Jim that's excellent. Julie you've got the final word.

Julie Yates: Thank you. I mean I would just echo some of what Jim has said in terms of using trusted voices in the community. We do within some of our screening programmes we use hairdressers to spread the message and to encourage people to come forward for screening so we can use some of these mechanisms some of these ways of working with vaccination programmes as well.  

I think it's it is important that we are going to have to build this into our normal business as usual because as Jim said it's marathon and these things are going to arise again, so we know that we're going to have to look at this alongside our flu programme, alongside other programmes and ensure that we can deliver all of this at the same time without tipping over the services that are there for other things we need like our GP services. So we're going to need to be smart in the way that we do this, but I think the key to it is collaboration, working together and building on our structures processes and the ways that we work together as a team.   

In terms of the young people when I'm quite hopeful with the young people and I think we shouldn't underestimate how much young people care about other people, about their own families, their grandparents and how much they actually want to get back to normal and they want to be able to travel and they want to be able to visit people safely. Not just safely from their own perspective but they're worried about transmitting something to somebody that they care about and that they love.

So I think I'd like to end on that point because we’re down on young people quite often and  I feel very positive about them that they can be ambassadors, they don't believe what's on the Internet - they're very savvy at picking out what's right and what's wrong. We just need to help them with that and I think we might be pleasantly surprised when we get down to those levels in the cohorts I certainly hope so.

Paulette Hamilton: Well we've got to end on a positive note and for me what I'd like to say to end this - I am really proud of how the local authorities across this country as reacted throughout this process.

We have had to learn new ways of working, we have had to learn how to work in collaboration to change the way we do things, but I believe that local government has really played a massive role throughout the pandemic but through this vaccine rollout.  I know we will continue to play our part; I know we will continue to be phenomenal. We will lead from the front. We will support where needed. We will carry when needed but the local authorities of cross this country and public health and social care have absolutely been phenomenal.

We have to remain positive. We have to remain alert. We have to understand that people have hesitancy because they don't understand everything they're being told. Once you tell them and once they get it they will do the right thing, but also for people like myself I cannot wait to go on another holiday!

So, on that note I'm going to say Jim it's been a pleasure as usual Jim McManus. Julie I've not met you before but Julie Yates you have been a star and Eleanor Eleanor Eleanor Eleanor you have given the national perspective in such a way that I couldn't have asked for anymore. So, you've made a wonderful panel it's been a brilliant session and thank you all very much.

Thank you for listening to the ‘Forget What You Think You Know’ podcast. If you enjoyed today’s episode hit the subscribe button and give us a rating. We look forward to seeing you next time.