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Clara McNeill offers an initial response to recent Government guidance in favour of a conditional vaccination mandate for staff working in older adult care homes in England. She discusses the reasons behind the mandate and how the protocol will impact staff and residents, and how it can be ethically defended.

Last week the Guardian reported that ‘Covid vaccinations are to become mandatory for care home staff’, and the BBC published that, ‘workers will have 16 weeks to get both jabs from the time regulations are approved by Parliament… [or] face being redeployed away from front-line care or potentially losing their job’. This striking statement is in response to an open government consultation, and follows recent reports making the case for mandatory Covid-19 vaccination for frontline healthcare workers (FHCW) in England.


According to the independent SAGE Social Care Working Group, people living in care homes have been particularly impacted by the Covid-19 pandemic, many of whom were already frail and vulnerable, which increases their risk of serious sequelae or death from Covid-19. Moreover, Covid-19 disproportionately affected FHCW, who can transmit the virus to patients, colleagues, and the wider community. Notwithstanding FHCWs’ obligations to take reasonable measures to limit infection through measures like handwashing, wearing Personal Protective Equipment and engaging in Lateral Flow Testing schemes, ONS Data indicates a 19.5% increase in excess deaths in care homes since March 2020, with care home residents accounting for almost a third of total registered deaths from Covid-19 in England. There is thus a pressing need to reduce transmission in healthcare settings, and any proportionate policy which increases vaccination uptake and effectively reduces infection, morbidity and mortality is worthy of consideration.


Voluntary vaccination uptake so far has been high in the UK, but SAGE experts advise 80% of FHCW working in care homes with older adults, and 90% of residents, must be vaccinated in order to afford the minimum level of protection against Covid-19 outbreaks. Nonetheless, as of mid-June, only 84.1% of adult care home staff in England had their first dose and with sources indicating vaccine hesitancy amongst staff. Recent data indicates 64.7% of older adult homes in England have attained the recommended dual threshold for the first dose, and only 40.5% for the second, revealing much progress must be made to afford residents and staff appropriate protection against Covid-19.


Mandating vaccination can be ethical and legal if it is both necessary and proportionate, and statistical data thus far has shown persuasion has been an insufficient mechanism to ensure sufficient uptake for FHCWs. The vaccine has already had a significant impact on reducing hospitalisations and deaths, with studies indicating that one dose can reduce transmission by up to a half. Further, a Whitehall source indicated pre-existing guidance that doctors should take the Hepatitis B vaccine suggests there is precedent for a mandate and analogous studies on mandated influenza vaccinations are proven to be the most clinically and cost effective strategy to attain optimum uptake.


Some care homes have already moved towards making Covid-19 vaccinations mandatory, Barchester Healthcare group, revealed earlier this year that all staff for whom the vaccination was not medically contraindicated were expected to have their first dose by 23rd April. Likewise, Care UK adopted a ‘no jab, no job’ policy for new hires. As Dan-Cohen attests, authority can result in compliance, loyalty and adherence, but so too can it ‘provoke resentment and defiance’, which could make any mandate counter-productive. There are fears that the new regulations could worsen existing staff shortages, leaving an already struggling sector in a worse state. FHCWs experienced serious trauma throughout the pandemic; thus, this mandate must be implemented in a manner which is respectful and cognisant of the impact Covid-19 has had/ is having on FHCW.


The mandate must recognise the cultural and informational needs of diverse racial and ethnic minority groups which have been disproportionately impacted by the pandemic, particularly as they have over-represented in frontline healthcare work and would be disproportionately affected by a vaccine mandate.  Thus, more resources must be invested in engaging in information sharing and trust building activities with affected communities. Moreover, to limit the burdens associated with mandatory vaccination, all FHCW must have transparent access to evidence about the vaccine’s safety, and the vaccine must be financially and logistically accessible and accompanied by robust vaccine injury compensation mechanisms.


Within care home settings, vaccine refusal has serious ramifications for staff and residents, which, when combined with the severity of Covid-19, justifies some form of mandatory vaccination policy for FCHWs. Implementing a conditional employment requirement is defensible and is likely to reduce viral transmission of Covid-19 from unvaccinated FHCWs to patients and colleagues and satisfy ethical and professional requirements. The risk to residents and the community posed by unvaccinated FHCWs outweighs concerns of coercion if it is implemented through a transparent and inclusive process which engages with people from diverse social groups.


Clara McNeill, Master of Jurisprudence candidate (ethics of vaccine compulsion for healthcare professionals), Durham Law School