Compulsory flu jab for NHS staff – moral duty, or morale wrecker?

Opinion is divided about how best to boost nurses’ uptake of the influenza vaccine

Opinion is divided about the best way to boost nurses’ uptake of the influenza vaccine

Picture: SPL

Almost one in five NHS employers in the UK (18%) has discussed the possibility of making the flu vaccine compulsory for its staff, a Nursing Standard investigation reveals.

The UK recently experienced its worst flu season in seven years, with the highest rates of influenza since 2011, according to Public Health England (PHE).

At its peak in January this year, strains of the virus, such as H3N2 (known as ‘Aussie flu’) caused 758 hospital admissions, with 240 patients treated in intensive care units in England alone.


confirmed cases of flu in Wales over the winter season 2017-18

However, the idea of compelling health service staff to have the flu vaccine divides professional opinion within the health service.

Last year NHS Employers sided with the National Institute for Health and Care Excellence (NICE) in opposing mandatory flu vaccination for the workforce. NICE states: ‘Qualitative evidence indicates such policies can negatively affect staff morale, leaving them disempowered, lacking autonomy and resentful of the perceived undermining of their professional work ethic.’

It adds that there is a ‘wealth of evidence that multicomponent interventions do not need to be mandatory to be effective’.

Sir Bruce Keogh.
Picture: Tim George

But in January, NHS England medical director Sir Bruce Keogh and England’s chief medical officer Dame Sally Davies raised the question of mandatory staff vaccination as a potential option for employers, arguing that health workers have a duty of care to their patients to have the vaccination.

‘I have the flu vaccine every year, but if they make it mandatory, I won't. No one can force nurses to get injected’

Nursing Standard reader

Comments posted in response to a Nursing Standard story on the issue suggest many nurses would not react well to being told they have to have the jab.

One said: ‘I have the flu vaccine every year, but if they make it mandatory then I won't have it. No one can force nurses to get injected.'

Another said: 'It should be a personal choice whether to have the flu vaccine or not.'

Public Health England (PHE) medical director Paul Cosford recently acknowledged that the ‘psychological and cultural aspects of a move to mandation’ are important.

Dame Sally Davies. 

Professor Cosford told a committee of MPs: ‘We could end up with some groups of people being even more suspicious of vaccination than they are already, which could be counterproductive. It is a complicated area.’

What does the evidence say?

Some NHS staff say their concern about mandatory flu vaccination is evidence-based.

A Cochrane review on the efficacy of the vaccine in healthy adults, published in February, concluded there is little difference between influenza rates for those who are vaccinated and those who are not.

‘Healthy adults who receive inactivated parenteral influenza vaccine rather than no vaccine probably experience less influenza, from just over 2% to just under 1% (moderate-certainty evidence),’ it said.

‘Certainty of evidence for the small reductions in hospitalisations and time off work is low.’


deaths this season in Northern Ireland among intensive care unit patients with influenza

According to data received by Nursing Standard from 73 NHS providers in the UK, a total of 384,540 nursing days have been lost since 2015 because of flu symptoms or colds. In total, 108,932 nurses took time off work for these illnesses.

Most employers do not differentiate between flu, colds and coughs in their records. As a result, it is difficult to gauge rates of flu in the nursing workforce, although exposure from patients to strains of influenza increases the chances of transmission.

Wide variation in uptake 

Despite the risks of exposure to the virus, only 68.7% of NHS staff chose to be vaccinated in England this year. There is no defined optimal rate of workforce vaccination in England, but PHE says an 'ambition target' will be published soon.

In Wales 56.9% of NHS staff took up the flu vaccine. The target is 60%.

Shona Robison.
Picture: Paul Edwards

Scotland’s health secretary Shona Robison said in January that around 40% of healthcare workers had been vaccinated. Scotland has no target uptake rate.

In Northern Ireland, where there is a 40% uptake target, 33% of NHS staff chose to have the flu vaccine this winter.

A Department of Health spokesperson there says the Public Health Agency Northern Ireland and health and social care trusts are ‘actively engaged’ in improving uptake for front-line healthcare workers.

‘While uptake has improved, it is acknowledged that there is still room for improvement,’ the spokesperson says.

‘All healthcare workers should be vaccinated unless there are contraindications’

Paul Cosford, Public Health England medical director

Uptake of the flu vaccine is highly variable at organisational level.

According to Professor Cosford, there are 21 trusts in England with staff vaccination rates of more than 80%, while for others the figure is 30%.

Data collected by Nursing Standard reveals that 13 organisations – 18% of the 73 that responded – have considered making flu jabs compulsory, although only one has actually done so.

Since September 2017, Barking, Havering and Redbridge University Hospitals NHS Trust in east London has included a requirement to have the flu vaccination in it employment contracts for all new clinical staff. This has been credited with the trust meeting its vaccine uptake target (see box).  

Professor Cosford says: ‘We would welcome a debate about this. For some, flu can be a particularly serious illness and healthcare workers have an important role to play in protecting the health of the public.’

At a Commons Science and Technology Committee meeting in March, the professor was clear on his position.

He told MPs: ‘I will give you a stronger view than my colleagues. It is perfectly reasonable that we have different views.

‘I think the position should be that all healthcare workers are vaccinated unless there are contraindications.’

The trust that puts flu vaccination in the employment contract

One of the trust's hospitals – Queen’s in Romford. Picture: Alamy

Barking, Havering and Redbridge University Hospitals NHS Trust in east London has become one of the first NHS employers to make the flu vaccination mandatory for some staff.

Since September last year, all new clinical staff have it written into their employment contracts that they must have the flu vaccination. 

The trust, which has been shortlisted for the NHS Employers 2018 flu fighter awards, claims it wants to ‘send a clear message about our aspirations and expectations to all new staff, particularly those in clinical roles’.

If new employees refuse the vaccination it ‘will be handled locally, opening the door for a conversation between the person and their manager to discuss and resolve’, a trust spokesperson says.

Trust director of people and organisational development Deborah Tarrant said: ‘We've worked very hard in recent years to improve our flu jab take up and have been pleased with the results.

‘This year we hit our 70% target, an improvement of more than 10% on last year's figure.'

The trust ran a flu awareness campaign called ‘The Good, the Bad and the Bugly’ and installed a flu vaccination tent in the trust’s main entrances.

Ms Tarrant added: ‘It takes time to change the culture, and challenge some of the myths which people believe about the flu vaccine, but using this variety of tactics seems to be paying off. We won't stop pushing but it's been encouraging to see some positive results.’

Ultimately, any decision to mandate the flu vaccine in England lies with the Department of Health and Social Care (DH), and with the devolved health administrations in the rest of the UK.

‘It’s the best protection we have’

A DH spokesperson says: ‘Staff uptake of the vaccine has increased significantly over recent years, but there is still too much variation.

‘Flu kills and the best protection we have is the vaccine.

‘We strongly urge all healthcare workers to get the flu vaccine during the winter months, and will keep evidence on this area under review.’

‘There are plenty of examples where organisations achieve high uptake without compelling staff to have the vaccine’

Helen Donovan, RCN professional lead for public health

The health departments of Scotland and Wales say they have no intention of making flu vaccinations mandatory, although Northern Ireland says it is happy to discuss the issue.

A Northern Ireland Department of Health spokesperson says: ‘We would be keen to consider all options for improving the flu vaccine uptake rate of health and social care staff and would be happy to participate in any UK-wide discussions.’

A Scottish Government spokesperson says: ‘While vaccination programmes are introduced on the basis of advice from expert groups, our aim is to ensure people are able to make informed choices about whether or not to accept the offer of vaccinations. Indeed, Scotland has among the highest levels of uptake for vaccines in the world.’


outbreaks of acute respiratory illness, mainly influenza outbreaks in care homes, were seen over 12 weeks in Scotland

A Welsh Government spokesperson says: ‘There are no plans at present to introduce compulsory flu vaccination for NHS staff, however we will continue to review our position.’

RCN professional lead for public health Helen Donovan says: ‘We encourage all nursing staff to have the vaccine but do not support penalties if staff refuse – we agree with the guidance from both NICE and NHS Employers on this.

‘There are plenty of examples where organisations achieve high uptake without compelling staff to have the vaccine.’

Given the range of opinions about the flu vaccine for NHS staff, and the rift between those who would mandate the jab and those who would not, compulsory vaccination still appears a long way off.

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Stephanie Jones-Berry is a freelance health journalist

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