key: cord-0682264-64ip0e7w
authors: Savic, Louise C.; Savic, Sinisa; Pearse, Rupert M.
title: Mandatory vaccination of National Health Service staff against COVID-19: more harm than good?
date: 2022-02-03
journal: Br J Anaesth
DOI: 10.1016/j.bja.2022.01.030
sha: 7820161c5b588dc7adee91e03251a9a1c73ea0aa
doc_id: 682264
cord_uid: 64ip0e7w

Despite the clear benefits of vaccination against COVID-19, there is growing unease relating to the policy of mandatory vaccination of health and care staff in England. Healthcare staff, and in particular doctors, speaking out on this issue may inadvertently provide a narrative that undermines the objective of achieving widespread vaccination of populations against this serious disease.

The past two years have been incredibly difficult for healthcare staff, who have found themselves at the epicentre of a global pandemic with the eyes of society upon them.

Many became ill with COVID-19; some did not survive. Each of us understood that we might be next. Two years on, and the pandemic is a weary routine. Armed with a better understanding of virus transmission and adequate supplies of personal protective equipment, National Health Service (NHS) staff caring for COVID-19 patients in the UK are now much safer. But we all remember the early days when we pushed doubts about safety to the backs of our minds. It seems natural that we would seize the opportunity to be vaccinated against a virus that has done so much harm to our patients, and most of us have done exactly that. But not all. Amongst UK healthcare workers, there are still some who worry about vaccination. In previous years, they quietly avoided invitations to get the 'flu jab in the hospital canteen. These aren't militant 'anti-vaxxers' who propagate lies about vaccines in pursuit of an uncertain mission. These few NHS staff are vaccine hesitant.

The UK government decision to mandate vaccination for all patient-facing health and social care workers in England is a difficult one. On one hand, why would we not do everything possible to protect ourselves and our patients? On the other, we are subject to a legal mandate that takes a personal health decision out of our hands. Faced with losing their job, it seems inevitable that sooner or later vaccine hesitant staff would speak out. It was a genuine shock for many to find that first voice coming from an intensive care doctor. The television footage of Steve James discussing his concerns about mandatory vaccination with government Health Secretary Sajid Javid took place during a visit to a London hospital ICU where James has worked during the pandemic. 1

In this conversation, which has been shared more than a million times on social media, Reduced severity of illness also helps society to function more normally outside the healthcare setting. The nuances around individual differences in immune response do not alter the fundamental fact that widespread vaccination protects everyone. There can be no doubt that vaccination is the cornerstone of recovery from this, and future, pandemics.

It has been disappointing to see the negative impact such uninformed comments have had on the public discourse around vaccination. In the days after the footage of James' interview was released, social media was awash with healthcare staff trying to redress this balance by openly supporting and promoting vaccination. Social media has also seen many inappropriate and personal attacks on James, which has not helped and may J o u r n a l P r e -p r o o f seriously impact on his well-being. The question is how and why did the issue of vaccination of health and care staff become so polarised, and was this avoidable?

Whilst UK medical Royal colleges have been relatively muted in their response to mandatory vaccination of their members, they have not been silent. In a recent joint statement, the Royal College of Anaesthetists and the Faculty of Intensive Care

Medicine firmly encouraged all NHS staff to be vaccinated against COVID-19. 5 But the statement also highlights the need to listen to the concerns of NHS staff who have chosen not to be vaccinated, and to support them to make good health decisions. A statement by the Academy of Medical Royal Colleges also expresses clear support for vaccination of all health and care staff, 6 highlighting guidance from our regulator the General Medical Council that doctors should be immunised against common serious communicable diseases. 7 The Academy goes further, explicitly stating that mandatory vaccination is 'not sensible or necessary'. The basis for the Academy position is not an ethical one, but a practical concern that a mandatory vaccination policy may cause protests which distracts from the primary objective of getting as many staff vaccinated as possible.

People can be categorised into those happy to be vaccinated, those who are vaccine hesitant, and those who completely refuse. Whilst mandating vaccination may improve compliance among some groups, it is also likely that the threat of sanctions in the absence of dialogue will push other vaccine hesitant staff to adopt a more extreme position. Would the outspoken conversation on ICU with the Health Secretary would ever have taken place if a less severe sanction than dismissal had been chosen?

Unfortunately, the opportunity for a balanced discussion around the issue of unvaccinated staff has now been lost. A mandatory policy precludes any flexibility in how we might address the issue among these valued members of staff, for example with regular testing or individualised assessment of immunity and transmission risk.

J o u r n a l P r e -p r o o f Instead, we risk further alienating the very people with whom we should be working closely to find solutions, allowing them to retain frontline roles whilst protecting patients from infection. This topic is set to become a source of increasing acrimony over the coming weeks. There are no easy answers for where we go next. 

COVID-19 Cases and Hospitalizations by