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30 June 2021

Why coercion is not the solution to the care-home vaccine problem

Relying on testing to ensure care home safety is imperfect, but making vaccines compulsory will come at a cost.

By Phil Whitaker

The only part of the pandemic response the Johnson government has got right has been the vaccination campaign. From the decision to establish a task force and to appoint, in Kate Bingham, a genuinely capable leader, through to the hedging of bets across a range of potential vaccine candidates, it has been a success story.

This being Covid, though, a government misstep was always possible. The decision to make vaccination compulsory for care workers in England is a case in point. At first glance, this seems a straightforward clash of rights: the right of vulnerable people to be looked after by Covid-free staff vs the right of staff to decline vaccination. 

The current approach to trying to ensure care staff are Covid-free – twice-weekly testing – is imperfect. Lateral flow devices interrupt at most 70 per cent of potential transmission. Vaccination also reduces transmission, perhaps by as much as 90 per cent, though that figure may be lower with the Delta variant. According to analysis by the Nuffield Trust, excess mortality in care homes during the second wave in late 2020-early 2021 was substantially lower than in the first wave. A major difference will have been the sector’s enhanced capacity to protect residents through access to adequate PPE and testing capacity. We now have extremely high levels of vaccine coverage among residents, too. But high rates of staff immunisation will undoubtedly contribute something, so compulsion makes perfect sense – to those who are persuaded that vaccination is a safe and rational thing to do.

Research from Liverpool in March, when care staff vaccination rates in the city were barely above 50 per cent, identified vaccine hesitancy as a major factor. Concerns included a lack of adequate research into safety as well as worries about allergic reactions and supposed effects on fertility. Across society generally, vaccine hesitancy is highest among minority ethnic populations and socio-economically deprived communities. Those undertaking care work are disproportionately drawn from these groups.

[See also: Frank went in for a Covid jab, but what he got was a diagnosis that may have saved his life]

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One way to tackle this is to engage people, respect that they have genuinely-held beliefs, and seek to shift perspectives through dialogue and information. Another might be to tell them they are wrong and if they don’t fall in line they will lose their jobs. The former approach will raise rates, but they will never reach 100 per cent. The latter will achieve that, but at what cost?

A sense of control is at the heart of vaccine hesitancy. For communities that experience endemic powerlessness as a result of poverty, discrimination or alienation, distrust of those wielding power offers fertile ground on which suspicions and misinformation can flourish. Non-cooperation is a rare opportunity to exert agency. Respectful engagement has the potential for hesitant individuals to change tack but retain autonomy. Coercion – by people still in their jobs despite decisions that devastated the care sector in the first wave – quashes that.

As with so many government policies, there is a failure to consider unintended consequences. We may end up with 100 per cent of those still remaining in care work immunised, but the exertion of dominance will intensify distrust among hesitant groups. The negative impact on vaccine uptake outside the care sector may create far more Covid casualties than this misguided policy sought to prevent.

For healthcare professionals there is an ethical dimension. Consent, informed and freely given, is a prerequisite for any medical intervention. How will I feel when confronted by a care worker, sleeve rolled up but eyes downcast, when they come to me for a job-preserving Covid vaccination?