It was recently announced by Health Secretary Jeremy Hunt that English hospitals will share £500 million in extra winter funding for A&E departments over the next two years. This seemed like great news in the context of on-going issues at Lewisham A&E and others. However, there were conditions. A&E departments will only receive this money if they achieve a target of 75% of their staff being vaccinated against influenza this year. This is an ill-thought out initiative that speaks less to the long-term strategic organisation of health care, and speaks more directly to short term initiatives aimed at incentivising hospital funding. It demonstrates a growing disconnection between the Department of Health and the realities of service delivery and really is best regarded as a show of cynicism, grabbing a headline with a target that few, if any, hospitals are likely to achieve.
Why is it short-term cynicism? The targets for the current flu season were announced in September. This timeframe takes no account of the fact that hospitals order their vaccine stocks in spring, normally on the basis of the previous year’s uptake. Vaccine supplies to hospital staff can only be increased at the expense of other groups. That is to say, this perverse incentive means that fit NHS staff will now be vaccinated at the expense of vulnerable citizens! Similarly, occupational health departments are stretched to deliver current levels of vaccination and can only increase this at the expense of other important work. Agency staff can be bought in but this is costly and diverts funds from other uses- such as additional cover for A&E this winter.
What about the effectiveness of the jabs? There is little evidence that the policy will have a significant impact on sickness absence in hospitals during the winter. In a current study, we are looking at the setting of flu vaccination targets in Wales (since 2011/12 Public Health Wales have been encouraging hospitals towards a 50% uptake target – most healthcare organisations remain short of this target). One of our informants from an occupational health setting commented:
…the majority of absence throughout the months from November to March is probably due to short term, other viral type infections,that have nothing to do with influenza. And if you’re trying to create a positive, creative, i.e. I’m a supportive employer, then basically that’s sending out the wrong message. It’s well ‘We’re doing this because we want to protect the organisation rather than caring for you as an individual person’.
In this extract the severity of flu as a problem for staff is brought into question. Flu is popular shorthand for a range of low-level viral respiratory illnesses that are rarely worth the investment to diagnose definitively (expect perhaps in the context of vulnerable populations), given the general short term duration and level of severity. No-one knows what proportion of staff who phone in sick with ‘flu’ are actually suffering from influenza strictly defined. If they have had the jab, they will probably describe the illness differently, but they are no more likely to turn up for work – and nor should they.
There is an attendant moral agenda at play here. The Chief Medical Officer for England has long had a bee in the bonnet about the moral obligations of health care workers to accept vaccination in order to avoid transmitting infection to vulnerable groups. The offer of a target-based incentive creates the situation where hospital management can pressure hospital staff to get vaccinated. This raises a subsequent question about the ethics of tying a healthcare intervention to organisational funding structures. The incentive would be more acceptable if we were talking about monthly sales figures, but we are talking about a target based on a physical intervention upon that person. Surely this is equally questionable morally and ethically? Should people be made to feel guilty about a purported moral obligation when there is little evidence to support the scale of the problem, the efficacy of the intervention, or even the philosophical position that it is their responsibility?
The experience in Wales shows that a combination of persuasion and mobile vaccinations can achieve close to 50% uptake. This 75% target is only achievable by aggressive management action. International attempts to compel health care workers to accept influenza vaccination, have consistently run into significant problems with the courts, in terms of the human rights of employees or in terms of the liability of institutions for any consequent harm. There is no evidence that the Department of Health has reflected on these issues before announcing the policy.
This initiative seems to solve an impending PR disaster over winter A&E provision by setting English hospitals up to be the scapegoats, for failing to reach an implausible target. A greater uptake of influenza vaccination by health care workers may well be desirable – although it would be nice to have better evidence of the benefits. However, it is more likely to be achieved on models of partnership (as in Wales) rather than by these bullying tactics. Does the Department of Health want this initiative to succeed or do they simply want to announce a £500 million spend that they know they will never have to deliver?
About the Authors: Rachel Hale is currently completing a PhD at the University of Nottingham about the healthcare worker influenza immunisation programme in Wales. She also works part-time as a Research Associate at Cardiff University. Robert Dingwall is a consulting sociologist and Director of Dingwall Enterprises Ltd. He has had a varied career in the sociological study of medicine, law, and science, and is currently a part-time professor at Nottingham Trent University.