Bolton Council: improving childhood vaccination uptake with a focus on MMR and a collaborative, quality improvement approach

Bolton is a diverse metropolitan borough in Greater Manchester with a population of approximately 310,085. It has a younger demographic than the national average, a rising multicultural population and features both affluent areas and significant pockets of national deprivation.

Bolton has generally been above the England average for uptake of both MMR1 and MMR2 but has seen a steep decline in uptake since 2016/17 that continued through the Covid pandemic. Collaborative work to address this challenge began in 2023 with a ‘deep dive’ to understand local data, drawing on a review of key literature and guidance to develop a local childhood immunisation action plan. This action plan identified three themes for action that have provided a continuous framework for the subsequent work:

• accessibility to vaccines
• data quality
• engagement with parents, carers and communities.

The COM-B behavioural science model was used in a system-wide workshop to generate specific recommendations for action under each of these themes. A Childhood Immunisation Strategy Group was established to take forward this work, led by the LA Public Health Team and including representatives from locality ICB primary care and business intelligence, CHIS, provider representatives (primary care, 0-19 service and school-aged immunisation service) and leads from early years. Two key phases of work to improve childhood vaccination have followed. 

Declaration of the national measles incident in early 2024 brought more focus onto local Measles elimination plans and the uptake of MMR. The Greater Manchester response included Section 7A commissioning of an enhanced MMR vaccination offer, with targeted catch-up vaccinations in primary schools, secondary schools and colleges, and enhancement of communications on measles and MMR. In this context Bolton Council worked with key local partners to develop a business plan submission to improve MMR uptake. Informed by the deep dive work this plan included: 

• locality insight work to understand barriers to uptake
• development of a social media and marketing ‘Say Yes’ campaign and amplification of national and regional communications on measles and MMR
• training for community champions and practitioners (RSPH accredited ‘Encouraging Vaccination Uptake’ course delivered through Bolton College)
• a focus on data, with establishment of a local data working group and MMR data dashboard, enabling regular review and a targeted approach to the neighbourhoods and practices with the lowest uptake
• a three-month Local Delivery Pilot led by the Bolton GP Federation (an alliance of local PCNs) and VCSE, focused in the Central and South PCN areas, which have the most significant gaps in 0-30 aged MMR vaccination uptake. Social media and local VCSE group channels were used to deliver positive vaccination messaging, practice lists were analysed to identify patients with outstanding vaccinations, and practice staff (clinicians, social prescribers, community care co-ordinators) mobilised to deliver telephone call and recall, directing patients to an offer of vaccination through drop-in community clinics, GP practices or the Town Centre ‘Health Hive’. 

There was significant learning from the targeted Local Delivery Pilot in the South and Central neighbourhoods:

• incorrect coding in practice records undermined the efforts of the telephone call and recall activity (compounded similar problems for the national call and recall campaign)
• the myths of autism risk in connection with MMR vaccination are still a concern for some parents and carers
• variation in workforce confidence to tackle myths and have ‘better conversations’ to address vaccine hesitancy
• evaluation of the social media campaign highlighted the benefits of using different media channels (eg Tik Tok) and local influencers
• a potential opportunity to review ‘whole household/family’ vaccination history to develop a more targeted offer. 

Overall, the measurable returns in vaccination uptake through the direct efforts of the pilot were disappointing (53 vaccines given, the majority in the Town Centre ‘Health Hive’), with significant time and effort invested across the elements of the pilot. Similar projects in neighbouring Local Authorities have shown more significant uptake, albeit with intensive resourcing. This highlights that success can be context specific and influenced by a range of factors and challenges (eg local outbreaks being a ‘call to action’, operational factors, impact of seasonality, sustainability). It is harder to measure the positive impact of awareness raising and increased profile of the vaccination programme, and the pilot made over 500 contacts made offering advice, guidance or free health checks.

Key learning to take forwards from the pilot: the need to continue to build on relationships, especially with VCSE, neighbourhood and faith organisations, operational lead-in time to mobilise a bespoke offer, better understanding of how to effectively promote a non-standard offer (community clinics) and the success factors.

In April 2025 a collaborative whole-system workshop was held to share local data on MMR uptake, learning from the Local Delivery Pilot and a Quality Improvement Project in a local GP Practice and resources available from CHIS (comprehensive Childhood Vaccination Toolkit for practices, targeted Improving Immunisation Uptake Team offer) and Bolton College (RSPH courses). 

It was apparent from the local data on practice and PCN uptake rates for MMR1 and MMR2 that there was significant variation in uptake within clusters of practices serving similar populations.

The workshop highlighted the importance of getting the details right in the ‘business as usual’ vaccination offer, particularly the early childhood offer through GP practices, with opportunities to share good practice and deliver a more effective offer through small, impactful changes.

The key output from the whole system workshop was a re-design of the second phase of the MMR Business Plan delivery, jointly led by the Public Health and ICB locality team.

This phase has focused on a Quality Improvement Project delivered directly into GP practices with the lowest MMR uptake rates, based on uptake below 90 per cent for MMR1 or 80 per cent for MMR2, or with 50 or more outstanding MMR vaccinations for children aged 0-5.

This approach reflects the learning from the original deep dive which highlighted that accessibility, convenience and reassurance are critical factors in supporting uptake (including timing and availability of appointments). These are underpinned by practice processes that prioritise the vaccination offer and ensure accurate coding to support effective call and recall. 

The QI project has so far made an offer of support to 22 out of 49 practices in Bolton, of which 15 have engaged and eight are receiving continue input. The project offers bespoke support from a Clinical Nurse lead with expertise in vaccination programme delivery, practice systems and training. The approach is modelled on the CHIS IIU Team approach, but with strengthened local knowledge and a flexible approach including delivery of vaccination sessions. The QI nurse lead has also established a Bolton-wide peer network for practice immunisation leads as a forum for sharing good practice.
Interim findings from the QI project to date have highlighted key areas for improvement: correct coding, routine follow-up of DNAs after clinics and limited clinic availability as a major barrier to uptake. Vaccine hesitancy remains a challenge including MMR and autism concerns, distrust following Covid-19 and general lack of vaccine knowledge.

Language barriers are a challenge for non-English speaking families.

The project has identified examples of good practice: having a named admin immunisation lead, routine clinician follow up of DNAs, clear alerts on patient records (“not up to date with immunisations”) and refusal review processes. These strategies show better engagement, successful whole family catch ups and improved uptake (e.g. +3 per cent in 0–5s at one site). Tailored approaches include: 

• same day eight week checks + vaccination
• structured parental conversations resulted in high booking conversion (often >80% per cent). 
• use of yellow paper, consistent SMS prefixes, and clinician led hesitancy discussions improved outcomes. 

The project team is developing a series of cross-cutting, system level recommendations to include a focus on the management and response to DNAs and vaccine refusals, promotion of flexible clinic days/times and opportunistic booking by reception staff and use of universal alerts in patient records. Work is needed to raise the visibility of the vaccination offer and improve practice communications with parents/carers and to strengthen the link with health visiting teams, with routine MDT discussion of DNAs and consideration of safeguarding risks. 

Given the national and regional (Greater Manchester) initiatives focused on Measles, MMR and catch-up programme it can be difficult to dis-aggregate the impact of local quality improvement work on uptake rates. In 2024-2025 Bolton saw an increase in MMR 1 (Bolton 93.7 per cent, England 91.8 per cent) and MMR 2 uptake (Bolton 87.8 per cent, England 83.7 per cent), showing a potential indication of success for the local programme as a result of these collective efforts, but inequalities persist and the most recent uptake remains below the 95 per cent WHO target. 

The qualitative evaluation and learning from the local delivery pilot and practice QI project have given rich data and insight to inform further improvement activity. Our local experience supports the evidence that success is context specific and that locally designed, multicomponent interventions are needed to meet the needs of urban, ethnically diverse, deprived populations.

Next steps: extending the health equity approach

Development and delivery of the locality Childhood Immunisation action plan will continue around the three original themes, with an objective to strengthen the focus on inequalities and targeted approaches in line with the National Vaccination Strategy, including: 

• Access – completion of the QI project evaluation and promotion of good practice recommendations to improve BAU childhood vaccination programme delivery in primary care.
  Data – building on the local and Greater Manchester immunisation dashboards, undertaking a health equity audit analysis of MMR uptake (subject to data access) to inform tailored approaches to improving uptake (ie by deprivation, ethnicity and language), with the aim of further extending this to a HEA analysis of HPV uptake.
• Engagement of parents, carers and communities – based on learning from the evidence, local insights, local delivery pilot and QI project, to develop a sustainable model for promoting awareness and understanding of childhood vaccination, tailored to the needs of different communities.
• Governance – there is an opportunity to strengthen the assurance and visibility of immunisation programmes through the Bolton Health Protection Board, reporting into new locality Governance structures, and ensure vaccination programmes are considered in emerging neighbourhood health models.

Sarah Poole-Sutherland, Public Health Specialist, Bolton Council

Email: [email protected]