National Audit Office report on The rollout of the COVID-19 vaccination programme in England

The COVID-19 vaccination programme (the programme) met stretching and unprecedented targets, helping to save lives and reduce serious illness and hospitalisation, according to a report by the National Audit Office (NAO). As the programme continues to evolve in response to the COVID-19 pandemic and to new clinical advice and evidence about vaccines, there are some clear risks to be managed.

The vaccine rollout was the biggest and most complex vaccination programme in UK history. In line with its targets, NHS England and NHS Improvement (NHSE&I)¹ had vaccinated two-thirds of adults by 19 July 2021. By the end of October, 85% of adults had received two doses of the vaccine, and more than 87 million doses had been administered in total: over six times the number in the previous annual flu vaccination programme. This uptake exceeded NHSE&I's initial planning assumption that 75% of adults would take two doses.

Up to the end of October 2021, the COVID-19 vaccination programme had spent £5.6 billion out of total available funding of £8.3 billion for the two years to the end of March 2022, including £2.9 billion to purchase COVID-19 vaccines, and £2.2 billion on deploying the vaccine. By the end of October 2021, the Vaccine Taskforce (the Taskforce)² had put in place contracts or agreements with six suppliers for over 340 million doses of vaccines to be delivered to the UK by the end of 2022.

Securing the supply early and then maintaining this supply was crucial to the successful roll-out. The Taskforce's main initial objective was to secure enough vaccines for the UK population as early as possible. The Taskforce and its partners worked with a clear strategy and took a proactive approach to dealing with potential barriers and managing uncertain outcomes. For example, it purchased several different potential vaccines at an early stage, explicitly recognising that some might never be approved, and also set up a strategy to deal with potential surpluses.

The programme took steps to make the vaccine convenient to access. GPs and community pharmacists have ended up administering many more doses than originally planned - 71% up to the end of October 2021 compared with a planned 56%. NAO interviews with bodies involved in running the programme locally highlighted the goodwill, flexibility, and dedication that had been required to set up and run vaccination sites at such pace and scale. A combination of existing staff, returning healthcare staff, newly trained vaccinators and volunteers have administered vaccines. At its peak, the programme was estimated to need 60,000 vaccinators and 65,000 non-clinical staff.

Despite efforts to address inequalities, the uptake of COVID-19 vaccinations among some ethnic minority groups³ (based on the number of people receiving two doses) remained substantially below the national average as at the end of October 2021. Younger age groups also fell below the national average (64% of those aged 18-24 and 68% of those aged 25-29 were vaccinated with two doses at the end of October 2021). Meanwhile, in October 2021 only 29% of women giving birth had received at least two doses of the vaccine.

New digital tools also contributed towards the success of the vaccine deployment. The COVID-19 vaccination programme set up a national data system that allowed the NHS to identify, record and transmit vaccination data across the health and care system. Digital dashboards with detailed real-time analysis of uptake and supply were created to support programme leaders and manage key risks.

The amount of vaccines supplied but not used (wastage) has been much lower than the programme initially assumed: the NAO estimated that wastage for England, as at the end of October 2021, was around 4.6 million doses, or 4% of total supply. There was a particular challenge with expiring AstraZeneca doses after the JCVI's recommendation that people under 40 should preferably not be offered it. This meant that about 1.9 million doses delivered to local sites had to be written off.

Given the unprecedented circumstances of the pandemic and the programme's achievements up to October 2021, today's NAO report finds that it has been an effective use of public money to this date. There are now risks to the programme's continuing success that must be managed. Staffing issues, including burnout, and a lack of surplus capacity in the healthcare system present substantial risks in a context where there are still around 3.7 million unvaccinated adults.

Given the continuing uncertainties of the pandemic, at the end of 2021 DHSC felt it was too soon to set out a more sustainable, long-term approach to COVID-19 vaccination, but told the NAO it was planning to address this in 2022. It will need to consider the best organisational structure for the programme, and how future costs and other resources may need to differ from the current emergency response. NHSE&I should take additional steps to manage the vaccine workforce and examine how the programme can minimise its potential adverse impact on other health and public services, given that it is substantially the same workforce delivering all these services.

Gareth Davies, the head of the NAO, said:

"The vaccine programme has been successful in getting early access to what were brand new COVID-19 vaccines, securing supply of them, and administering them to a large proportion the population at unprecedented speed. 

"The programme must now redouble its efforts to reach those who are not yet vaccinated while also considering what a more sustainable model will involve as it moves out of its emergency phase."

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Notes for Editors

1. NHS England and NHS Improvement (NHSE&I) leads on operational delivery of COVID-19 vaccinations in England. It worked with Public Health England (PHE) on vaccine supply, storage and distribution. From October 2021, PHE's responsibilities transferred to the new UK Health Security Agency (UKHSA).
2. Created in April 2020, the Vaccine Taskforce (the Taskforce) has been responsible for securing vaccine supplies for the UK.
3. In the report, most measures of uptake use mid-2020 population estimates from the Office for National Statistics as a denominator.  This is the basis for the overall estimate of 85% of adults receiving two doses by the end of October 2021, and the breakdowns by age. Some uptake measures, including the breakdowns by ethnicity, use population estimates from the National Immunisation Management System. On the basis of this measure, the overall proportion of adults vaccinated with two doses by the end of October 2021, was 76%, with the lowest rates recorded for adults of Chinese origin (48%), Black Caribbean origin (49%), and Black Other origin (49%).