Annex A: public sector equality duty
Updated 30 October 2023
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Introduction
The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to:
- eliminate unlawful discrimination, harassment and victimisation, and other conduct prohibited by the act
- advance equality of opportunity between people who share a protected characteristic and those who do not
- foster good relations between people who share a protected characteristic and those who do not
The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality, but doing so is an important part of complying with the general equality duty.
Background
The UK government held a public consultation on proposals to make changes to the Human Medicine Regulations 2012 (HMRs) to ensure that the flexibilities established by amendments to these regulations in 2020 are maintained for a further time-limited period to support the continuing supply, distribution and administration of COVID-19 and influenza vaccines as we transition out of the pandemic.
There are 3 provisions in the HMRs that the consultation sought views on amending:
- regulation 3A (R3A)
- regulation 19 (R19)
- regulation 247A (R247A)
Regulation 3A and 19
Amendments to R3A allow for the final-stage preparation of the COVID-19 vaccines to be carried out by suitably qualified healthcare professionals without the need for manufacturing licences or marketing authorisations.
R19 allows COVID-19 and influenza vaccines to be moved between premises at the end of the supply chain by providers operating under NHS arrangements and the medical services of His Majesty’s Armed Forces without the need for a wholesale dealer’s licence.
Both regulations included a sunset provision of 21 March 2022, which was extended by further amendment to the HMRs to 1 April 2024, following consultation in 2021.
Both R3A and R19 have brought significant operational benefits. R3A has allowed the labelling of COVID-19 vaccines with a new shelf life after thawing, and preparation or reconstitution by the addition of the recommended diluent, without the need for a manufacturer’s licence or marketing authorisations.
This additional flexibility has meant that NHS teams have been able to use the skills and expertise of their staff in appropriate areas much more effectively, enabling safer systems of working, particularly at larger sites.
At the same time, the regulations have allowed GP practices to enter into collaboration agreements, enabling them to collaborate within a primary care network (PCN) grouping. COVID-19 vaccinations are not available in pre-filled syringes and so they continue to require preparation before administration to patients. The PCN grouping model relies on these regulations to allow healthcare professionals to prepare and assemble COVID-19 vaccines for patients, regardless of location or where the patients are registered.
Regulation 247A
R247A provided the mechanism that expanded the workforce who are legally and safely able to administer a COVID-19 or influenza vaccine without the input of a prescriber, using an approved protocol. It was recognised that, due to the need to rapidly roll out the programme at scale as soon as a COVID-19 vaccine became available, an alternative legal mechanism to administer vaccines using an expanded workforce was required, given the capacity constraints on those who were at the time able to prescribe or administer vaccines.
R247A introduced a new type of national protocol, which must be authorised by ministers in each of the 4 nations across the United Kingdom, that allows the classes of persons designated in the national protocol to safely administer a COVID-19 or influenza vaccine. This includes those who are:
- registered healthcare professionals who cannot ordinarily administer medicines or vaccines without the input of a prescriber (such as nursing associates, pharmacy technicians or operating department practitioners)
- non-registered healthcare workers (such as assistant practitioners, healthcare assistants or maternity support workers)
We have considered whether the proposal to amend the provisions under these regulations for a time-limited period, as set out above, could constitute conduct prohibited by the Equality Act 2010.
The provisions will apply to all persons irrespective of a protected characteristic and will not constitute direct discrimination on that basis.
These 3 regulations were introduced to provide regulatory flexibility to support the roll-out of the COVID-19 vaccination campaign and upscale the influenza vaccination programme in the UK, while protecting public safety. As such, it is expected that, if they are extended, they will continue to reduce health inequalities by helping to make these vaccinations available and accessible to all who are eligible.
The following sections look more closely at the potential impact these regulations could have on protected characteristic groups.
Policy objectives
The overarching policy objective of the proposed amendments to the HMRs is to enable the continued deployment of safe and effective COVID-19 and influenza vaccines to the pace and scale required, both now and in the future, while maintaining public safety.
Vaccines have proven to be the best line of defence against COVID-19, and for the prevention of seasonal influenza. If the provisions provided under R3A and R19 lapse (which will happen if we do nothing), and/or if the provisions in R247A are unable to be drawn on due to the ending of the pandemic, certain NHS vaccination activities would need to cease. This is likely to negatively impact provision and uptake of these vaccinations.
The proposed amendments to R3A and R19 will allow for continued flexibility for vaccine administration and support collaboration across the system. The proposed amendment to R247A will ensure that the current workforce administering COVID-19 and influenza vaccines under an approved national protocol may continue to do so in order to provide sufficient workforce as we transition out of a pandemic.
R247A is only permitted for use during a pandemic, and we temporarily wish to expand the provision while a permanent position is developed. R3A and R19 have sunset provisions, which mean they will cease to have effect on 1 April 2024 unless extended.
Who will be affected
These provisions are intended to give flexibility to the NHS to continue to deliver COVID-19 and influenza vaccinations at a pace and scale required for large-scale vaccination across the UK. As such, they are expected to continue to reduce health inequalities by helping to make these vaccinations available and accessible to all who are eligible for vaccination.
The proposed amendments are consequently expected to have significant benefits for staff, patients and service users.
Staff
R247A maintains the expanded workforce eligible to deliver vaccines, reducing wider pressures on the NHS workforce and delivery of services.
R247A and R3A also help to upskill healthcare professionals who do not usually administer or prepare vaccinations, while R19 supports staff by ensuring a swift and safe transfer of COVID-19 and influenza vaccines.
Patients
R247A, 3A and 19 all support the COVID-19 and influenza vaccination programmes to be delivered at scale, with appropriate workforce and operational flexibility to administer a vaccine without delay to ensure patients receive the vaccines they are eligible to receive in a timely way.
Service users
By ensuring the UK has the appropriate workforce and operational capabilities to deliver COVID-19 and influenza vaccines safely and efficiently, these regulations help to avoid pressures on other NHS services with substantial benefits for service users.
Evidence
The impact of the regulations was determined through data available in official statistics collected by organisations such as the Office for National Statistics (ONS), UK Health Security Agency (UKHSA) and NHS Digital that cover COVID-19 and influenza incidence and mortality, as well as academic papers where official statistics were not available.
The analysis provides the most up-to-date evidence where possible.
Official statistics
NHS Digital. NHS workforce - ethnicity facts and figures. 2023.
Office for Health Improvement and Disparities (OHID). Public health profiles - influenza. 2023.
ONS. Deaths involving COVID-19 by religious group, England: 24 January 2020 to 28 February 2021. 2021.
ONS. Deaths due to and involving influenza or pneumonia, England and Wales: 2001 to 2021 registrations. 2022.
ONS. Pre-existing conditions of people who died due to coronavirus (COVID-19), England and Wales. 2023.
UKHSA. National flu and COVID-19 surveillance reports: 2022 to 2023 season. 2023.
UKHSA. Seasonal Influenza vaccine uptake in GP patients: monthly data, 2022 to 2023. 2023.
Reports and academic papers
Davidson J, Banerjee A, Mathur R, Ramsay M, Smeeth L, Walker J, McDonald H and Warren-Gash C. ‘Ethnic differences in the incidence of clinically diagnosed Influenza: an England population-based cohort study 2008-2018.’ Wellcome Open Research 2021: volume 6, issue 49.
Department of Health and Social Care. Regulations 174A and 247A: one- year review. 2022.
Hudson N, Kersting F, Lynch-Huggins S, Macnaboe L and Sharrock S. ‘The experiences of UK LGBT+ communities during the COVID-19 pandemic: a review of evidence.’ NatCen Social Research. 2021.
National Audit Office. The rollout of the COVID-19 vaccination programme in England. 2022.
Scientific Advisory Group for Emergencies (SAGE). Factors influencing COVID-19 vaccine uptake among minority ethnic groups, 17 December 2020. 2021.
Raleigh N and Holmes J. ‘The health of people from ethnic minority groups in England.’ The King’s Fund. 2023.
UKHSA. COVID-19 reported SARS-CoV-2 deaths in England - COVID-19 confirmed deaths in England (to 31 December 2022): report. 2023.
Williamson EJ, McDonald HI, Bhaskaran K, Walker AJ, Bacon S, Davy S and others. ‘Risks of covid-19 hospital admission and death for people with learning disability: population based cohort study using the OpenSAFELY platform.’ BMJ 2021: volume 374, issue 1,592.
Impacts of COVID-19 and influenza on those with protected characteristics
The following analysis relies predominantly on data related to COVID-19, owing to limitations in published influenza data. The only routine and robustly collected influenza data that covers protected characteristics is broken down by certain age groups, pregnancy (2 criteria that determine whether someone is eligible for the influenza vaccine) and ethnicity.
Amending these regulations to maintain the ability to continue to effectively deliver the COVID-19 and influenza vaccination programmes is expected to have the following impacts on protected characteristics.
Note that consideration has been given to each of the 3 aims of the public sector equality duty:
- eliminating unlawful (direct and indirect) discrimination
- advancing equality of opportunity
- fostering good relations
Age
Severe COVID-19 rates by age
The risk of severe outcomes from COVID-19 increases with age.
Throughout the COVID-19 pandemic, hospital admission rates and deaths due to COVID-19 have been consistently highest in the older age groups. In England, from June 2022 to 4 June 2023, UKHSA data shows that the highest rates of confirmed COVID-19 cases are consistently in the 80 years and over age group, followed by the 70 to 79 age group. Within the same time frame, the weekly hospital admission rate for new COVID-19 positive cases has also been consistently highest in the 85 years and over age group, followed by the 75 to 84 age group.
Ensuring the eligible cohorts receive a timely offer of the COVID-19 vaccine supports a reduction in the absolute difference in risk of severe COVID-19 between populations who are eligible (who are on average older) versus those who are not eligible for booster doses.
Influenza rates by age
In December 2022, the point of the 2022 to 2023 winter influenza period when influenza cases peaked, the highest rates of influenza were found in the 5 to 14 age group, followed by 15 to 44 age group.
When analysing the most severe cases of influenza by age (those resulting in death), deaths involving influenza are consistently highest in those aged over 50. In recent years, the highest death rates involving influenza have been in the 90 years and over age group (2017, 2018, 2019 and 2020).
COVID-19 vaccine uptake by age
Table 1 below provides a breakdown of vaccine uptake by age for people aged 18 years and over.
This shows there is a clear trend of increasing uptake with age: there is almost a 45-percentage point difference in uptake from the youngest age group to the oldest age group who have received at least 3 COVID-19 vaccinations as of 2 March 2023.
Table 1: proportion of eligible people aged 18 years and over and their COVID-19 vaccination status, by age group, England, 8 December 2020 to 2 March 2023
| Age group | Completed primary course (at least 2 vaccinations) | Completed booster course (at least 3 vaccinations) | Has received no vaccinations | Partially vaccinated (only one vaccination) |
|---|---|---|---|---|
| 18 to 29 | 77.5% | 51.3% | 18.3% | 4.2% |
| 30 to 39 | 82.1% | 60.9% | 15.1% | 2.8% |
| 40 to 49 | 88.8% | 74.3% | 9.5% | 1.7% |
| 50 to 59 | 93.3% | 85.2% | 5.7% | 1.0% |
| 60 to 69 | 95.7% | 91.4% | 3.7% | 0.6% |
| 70 to 79 | 97.5% | 95.6% | 2.1% | 0.3% |
| 80 and over | 97.8% | 96.0% | 1.9% | 0.3% |
| All 18 and over | 88.9% | 75.8% | 9.3% | 1.8% |
Data source: ONS. Vaccination counts and proportions in people aged 18 years and over by socio-demographic characteristic, England: December 2020 to March 2023. 10 March 2023.
Influenza vaccine uptake by age
Table 2 below provides a breakdown of the different eligible groups, by age, who have received their seasonal influenza vaccine, excluding school-age children who received their vaccine via the school’s vaccination programme (note: the schools vaccination programme will be unaffected by these proposed regulatory changes).
This shows the highest uptake is in the oldest age group - those aged 65 years and over. This is at least 30 percentage points higher than the uptake for all 2 year olds, all 3 year olds, and those aged between 6 months and 65 years old who are in a clinical risk group.
Table 2: seasonal influenza vaccine uptake by age group (GP patients), England, 1 September 2022 to 28 February 2023
| Age group | Vaccine uptake (%) |
|---|---|
| 65 years old and over | 79.9% |
| 6 months to 65 years old and in a clinical risk group | 49.1% |
| Pregnant women | 35.0% |
| 50 to under 65 years old and not in a clinical risk group | 40.6% |
| 50 to 65 years old and in a clinical risk group | 62.4% |
| All 2 year olds (combined) | 42.3% |
| All 3 year olds (combined) | 45.1% |
Data source: UKHSA. Seasonal influenza vaccine uptake in GP patients: monthly data, 2022 to 2023 - 1 September 2022 to 28 February 2023. 23 March 2023.
Disability
Some of the health conditions that make individuals eligible for COVID-19 and influenza vaccines, due to their higher risk of severe disease, are also conditions that correlate with disability. This is because many of these health conditions have a substantial adverse impact on their daily life.
Disability alone does not always put an individual at higher risk of serious outcomes from COVID-19 or having a severe illness. However, some disabled individuals could be at a higher risk because of their older age, the setting they live in, or their underlying medical conditions.
Therefore, although there is no specific data on vaccine eligibility by disabilities, it is likely the eligibility rates for either of the vaccines are higher in the population considered to be disabled compared with the population with no disabilities.
Rates of severe COVID-19 and COVID-19 mortality rates by disability
In each wave of the coronavirus pandemic, age-standardised mortality rates involving COVID-19 for people of both sexes with varying degrees of disability of both sexes (those who said on the 2011 Census that their day-to-day activities were ‘limited a lot’ and ‘limited a little’, respectively) remained higher compared with non-disabled people.
This remains higher after adjusting for a range of socio-economic, geographic and demographic factors. The risk of death involving COVID-19 was 1.4 times greater for more-disabled men and 1.3 times greater for less-disabled men, compared with non-disabled men. The risk of death involving COVID-19 was 1.6 times greater for more-disabled women and 1.3 times greater for less-disabled women, compared with non-disabled women.
There is evidence showing, for the first 2 waves of the pandemic, that those with Down’s syndrome and cerebral palsy were associated with increased risk of COVID-19 hospital admission and COVID-19 related deaths, compared with the general population. There were also higher mortality rates in people with a hearing, vision or dual-sensory impairment, relative to those without impairments, (1.3, 1.4 and 1.4 times higher, respectively), after adjusting for a range of characteristics.
Influenza rates by disability
No data was identified on influenza rates by disability status.
As stated previously, some of the health conditions that make individuals eligible for the influenza vaccines (due to their higher risk of severe disease compared with those without an identified clinical risk) are also conditions that correlate with having a disability.
COVID-19 vaccine uptake by disability
Table 3 below provides a breakdown of vaccine uptake by whether individuals stated that they had a long-term physical or mental health condition that limited their day-to-day activities (the Equality Act 2010 measure of disability).
This shows that those who are disabled are more likely than those with no disability to have completed their primary and booster courses of COVID-19 vaccinations, while those with no disability are more likely than those with a disability to have had no vaccinations.
Table 3: proportion of eligible people aged 18 and over and their vaccination status, by disability status, England, 8 December 2020 to 2 March 2023
| Considered disabled | Completed primary course (at least 2 vaccinations) | Completed booster course (at least 3 vaccinations) | Has received no vaccinations | Partially vaccinated (only one vaccination) |
|---|---|---|---|---|
| Yes – day-to-day activities limited a lot | 87.9% | 77.7% | 10.0% | 2.1% |
| Yes – day-to-day activities limited a little | 91.0% | 81.3% | 7.2% | 1.7% |
| No | 88.0% | 73.6% | 10.1% | 1.9% |
Data source: ONS. Vaccination counts and proportions in people aged 18 years and over by socio-demographic characteristic, England: 8 December 2020 to 2 March 2023. 10 March 2023.
Influenza vaccine uptake by disability
There is no data available for influenza vaccine uptake by disability status.
However, there is data available from 2020 to 2021 of vaccine uptake by various high-risk health conditions (chronic obstructive pulmonary disease (COPD), diabetes, coronary heart disease (CHD) and stroke – all conditions that make someone eligible for the influenza vaccine), which are all conditions that increase the probability that the individual has a disability.
As seen in Table 4 below, the uptake by health conditions is relatively similar with CHD having the highest uptake rate (82.0%) and diabetes the lowest (76.7%). For the same period, all over-65s have an uptake rate of 80.9% - roughly the same rate as all 4 conditions.
Table 4: proportion of patients who received their influenza vaccination during the 2020 to 2021 period, by health condition, England
| Health condition | Vaccine uptake |
|---|---|
| COPD | 81.4% |
| Diabetes (aged 17 years and over) | 76.7% |
| CHD | 82.0% |
| Stroke | 79.4% |
| All aged 65 years and over | 80.9% |
| All considered at risk (all ages) | 53.0% |
Data source: OHID. Public health profiles - influenza. 2022.
Race
COVID-19 mortality rates by race and ethnicity
The pattern of COVID-19 mortality rates by race and ethnicity have changed as the disease has evolved.
For all ethnic groups, rates of deaths involving COVID-19 were highest prior to June 2021 when the ‘Delta’ variant became the most dominant variant in the UK.
Between 8 December 2020 (the start of the vaccination programme) and 12 June 2021 (the approximate end of the second wave of the COVID-19 pandemic), people from all ethnic minority groups (except the Chinese group and women in the white - other ethnic group) had higher rates of death involving COVID-19 compared with the white British population. During this time, the mortality rate was highest for those from Bangladeshi, Pakistani and black African ethnic groups.
During the period when the ‘Omicron’ variant of COVID-19 was dominant in the UK, evidence no longer showed ethnic minority groups having a significantly higher COVID-19 mortality rate compared with the white British group, and the data suggests there was a return to pre-pandemic all-cause mortality patterns.
During the pre-Omicron period of the pandemic, differences in mortality rate were found to be largely explained by socio-demographic factors, economic factors, health and, for some ethnic groups, lower vaccination coverage . Other factors are also likely to have contributed to the greater burden among ethnic minorities.
Influenza rates by race and ethnicity
Routine data is not collected on influenza rates by race or ethnicity.
A study of hospitalisations with clinically diagnosed influenza-like illness was completed in 2021 and looked at influenza rates of patients with recorded ethnicity who were aged 40 to 64 and did not have a chronic health condition (so were not eligible for an influenza vaccination) using Hospital Episodes Statistics from 2008 to 2018. The analysis found - after adjusting for age, sex and year - that medically attended influenza rate ratios were higher in South Asian, black and mixed ethnic groups compared with patients who were white.
COVID-19 vaccine uptake by race and ethnicity
Table 5 below contains rates of completing a COVID-19 booster course by March 2023 by ethnicity.
This shows the white British ethnic group had the highest rates of uptake (81.9%), followed by those who identify as Chinese (79.7%) and Indian (75.5%). In contrast, the lowest completion rates for the booster courses are those who identify as Pakistani (42.0%), black Caribbean (42.2%) and black African (43.2%). The ethnic groups with the highest proportion of those unvaccinated are those who identify as black Caribbean (35.1%) and white other (24.0%).
Table 5: proportion of eligible people aged 18 and over and their vaccination status, by ethnic group, England, 8 December 2020 to 2 March 2023
| Ethnicity | Completed primary course (at least 2 vaccinations) | Completed booster course (at least 3 vaccinations) | Has received no vaccinations | Partially vaccinated (only one vaccination) | |
|---|---|---|---|---|---|
| Bangladeshi | 84.7% | 53.9% | 11.9% | 3.4% | |
| Black - African | 74.4% | 43.2% | 21.3% | 4.3% | |
| Black - Caribbean | 61.7% | 42.2% | 35.1% | 3.2% | |
| Chinese | 90.6% | 79.7% | 7.7% | 1.7% | |
| Indian | 92.7% | 75.5% | 5.7% | 1.6% | |
| Mixed | 75.8% | 56.6% | 21.0% | 3.2% | |
| Other | 82.6% | 60.0% | 14.6% | 2.8% | |
| Pakistani | 81.6% | 42.0% | 14.3% | 4.1% | |
| White - British | 92.0% | 81.9% | 6.6% | 1.5% | |
| White - other | 73.6% | 54.9% | 24.0% | 2.4% |
Data source: ONS. Vaccination counts and proportions in people aged 18 years and over by socio-demographic characteristic, England: 8 December 2020 to 2 March 2023. 10 March 2023.
Influenza vaccine uptake by race and ethnicity
Table 6 below contains the uptake of seasonal influenza vaccines in 3 eligibility groups, by ethnicity, during the 2022 to 2023 season.
This shows the highest rates of uptake in the over-65 group and the 16 to 65 at-risk group were those who are recorded as white British (83.6% and 54.4%, respectively), whereas, for pregnant women, the highest uptake can be found in those recorded as Chinese (45.6%). The lowest uptake rates are found in the black or black British – Caribbean ethnic group across all 3 cohorts.
Table 6: proportion of GP patients and their seasonal influenza vaccine uptake data, by ethnic group (for selected ethnic groups), England, 1 September 2022 to 28 February 2023
| Ethnicity | Aged over 65 (%) | Pregnant women (%) | At risk and aged 16 to 65 (%) |
|---|---|---|---|
| Asian or Asian British - Bangladeshi | 67.7% | 34.6% | 52.0% |
| Asian or Asian British - Indian | 72.2% | 39.3% | 49.8% |
| Asian or Asian British - Pakistani | 54.8% | 25.5% | 34.2% |
| Black or black British - African | 50.2% | 27.1% | 37.1% |
| Black or black British - Caribbean | 48.5% | 13.5% | 28.0% |
| Mixed - any other mixed background | 66.1% | 29.5% | 38.8% |
| Other ethnic groups - any other ethnic group | 59.5% | 26.4% | 36.8% |
| Other ethnic groups - Chinese | 64.1% | 45.6% | 49.3% |
| White - British | 83.6% | 39.8% | 54.4% |
| White - other | 62.3% | 24.4% | 33.3% |
Data source: UKHSA. Seasonal Influenza vaccine uptake in GP patients: monthly data, 2022 to 2023 - 27 October 2022 to 23 March 2023. 23 March 2023.
Sex
COVID-19 rates by sex
UKHSA data covering May 2022 to May 2023 shows very little difference between males and females in the number of weekly confirmed COVID-19 cases per 100,000.
However, from the beginning of the pandemic to December 2022, deaths were higher in males (55.3% of deaths) than females (44.7% of deaths).
Influenza rates by sex
No information could be found on the sex differences of influenza incidence, hospitalisation or mortality rates.
COVID-19 vaccine uptake by sex
As seen in Table 7 below, women are more likely to have completed their primary and booster courses than men by around 10 percentage points. Similar numbers of men and women remain unvaccinated.
Table 7: proportion of eligible people aged 18 and over and their vaccination status, by sex, England, 8 December 2020 to 2 March 2023
| Sex | Completed primary course (at least 2 vaccinations) | Completed booster course (at least 3 vaccinations) | Has received no vaccinations | Partially vaccinated (only one vaccination) |
|---|---|---|---|---|
| Female | 89.5% | 76.8% | 8.7% | 1.8% |
| Male | 88.2% | 74.7% | 9.9% | 1.9% |
Data source: ONS. Vaccination counts and proportions in people aged 18 years and over by socio-demographic characteristic, England: 8 December 2020 to 2 March 2023. 10 March 2023.
Influenza vaccine uptake by sex
There is no published data available.
Sexual orientation
COVID-19 rates by sexual orientation
Data on the incidence, hospitalisations and death rates from COVID-19 or influenza in LGBT+ populations has not been robustly or routinely collected.
Evidence on the LGBT+ population’s experiences of the COVID-19 pandemic largely comes in the form of small-scale qualitative studies with non-representative, convenience samples. There is some evidence to suggest LGBT+ people may delay accessing health services due to fears and past experiences of discrimination.
Gender reassignment
COVID-19 rates by gender reassignment
There is no routinely collected, robust data on those proposing to undergo, undergoing or having undergone the process to reassign their sex.
Emerging findings suggest that trans people may delay accessing health services due to fears and past experiences of discrimination. Access to transition-related care is also an issue, with the pandemic causing delays to wait times to access gender dysphoria clinics.
Religion or belief
COVID-19 rates by religion or belief
In England, after adjustments for a range of factors, Hindu men and women, and Muslim men were disproportionately affected throughout the pandemic in the period 24 January 2020 to 28 February 2021.
From January 2022 to November 2022, the Muslim group, which previously experienced among the highest rates of COVID-19 mortality, saw notable decreases in COVID-19 mortality.
In contrast, males and females identifying as Christian or ‘no religion’ saw a small increase in COVID-19 mortality between the Delta and Omicron periods.
COVID-19 vaccine uptake by religion or belief
Table 8 below shows the variation in uptake of vaccinations by religious groups.
Rates for completing the primary course for all religious groups are greater than 80% - however, there is some variation, with the Muslim group having the lowest completion rate.
For the booster course, the Muslim group is significantly lower than all other categories: only 45% have completed their booster course (a 35 percentage point reduction on completion of the primary course).
The ‘other religion’ group has the highest proportion of members who are unvaccinated, followed by ‘religion not stated’ and the Muslim group. Muslims have the highest proportion of partially vaccinated individuals.
Table 8: proportion of eligible people aged 18 years and over and their vaccination status, by religious group, England, 8 December 2020 to 2 March 2023
| Religion | Completed primary course (at least 2 vaccinations) | Completed booster course (at least 3 vaccinations) | Has received no vaccinations | Partially vaccinated (only one vaccination) |
|---|---|---|---|---|
| Buddhist | 89.6% | 77.7% | 8.7% | 1.7% |
| Christian | 90.9% | 81.6% | 7.8% | 1.2% |
| Hindu | 95.2% | 82.0% | 3.6% | 1.2% |
| Jewish | 91.4% | 82.7% | 7.2% | 1.4% |
| Muslim | 80.3% | 44.6% | 15.7% | 4.1% |
| Sikh | 91.0% | 70.1% | 6.9% | 2.1% |
| Other religion | 80.7% | 64.9% | 16.8% | 2.4% |
| No religion | 88.2% | 73.7% | 9.6% | 2.2% |
| Not stated | 81.9% | 67.5% | 15.9% | 2.2% |
Data source: ONS. Vaccination counts and proportions in people aged 18 years and over by socio-demographic characteristic, England: 8 December 2020 to 2 March 2023. 10 March 2023.
In terms of the fourth vaccination, the continuation from third to fourth vaccination was highest among people identifying as Jewish (80.7%), Christian (78.9%) or having no religion (71.4%). However, less than half of the eligible Muslims (36.6%) have continued to a fourth vaccination. People who identify as Sikh (52.8%) also have low continuation.
A number of people may be opposed to vaccination in principle due to their beliefs, either religious or non-religious. These beliefs may be due to concerns as to whether the vaccine is compliant with the dietary practices of major faiths or with their ethical positions around medical interventions.
Pregnancy and maternity
COVID-19 rates by pregnancy
Increased severity of COVID-19 disease in pregnancy was reported after the first wave of the pandemic. Pregnant women who develop severe disease have increased rates of admission to intensive care, need for invasive ventilation and pre-term delivery.
Analysis completed by the ONS has found that, among both pregnant and non-pregnant women, age-standardised rates of COVID-19 hospital admission were lower among those who were vaccinated compared with those who were unvaccinated when first infected.
COVID-19 vaccination was associated with a similar reduction in the rate of COVID-19 hospital admission in pregnant and non-pregnant women, suggesting that vaccination is as effective in pregnant women at reducing COVID-19 hospital admission as it is in non-pregnant women. Furthermore, the data suggests being vaccinated reduces the risk of hospital admission in a similar way for both women infected with COVID-19 during pregnancy and women who are not pregnant when they are infected.
In December 2021, following the recognition of pregnancy as a risk factor for severe COVID-19 infection, the Joint Committee on Vaccination and Immunisation recommended, and the government accepted, that pregnancy should be added to the COVID-19 clinical risk groups.
To date, all clinical risk groups - including pregnant women - have been included in autumn campaigns.
Influenza rates by pregnancy
No data is available on the number of pregnant women testing positive or being hospitalised due to influenza.
COVID-19 vaccine uptake by pregnancy
In the 26-month period between January 2021 and February 2023, of the women who gave birth and their vaccination status was known, 46.6% received one dose of COVID-19 vaccine prior to giving birth, 40.5% received at least 2 doses and 20.7% had received 3 doses.
Through September 2022 to February 2023 (the autumn booster campaign period), 25.2% of women had not received a COVID-19 vaccine before they gave birth.
Influenza vaccine uptake by pregnancy
Although being pregnant is an eligibility criterion for receiving the influenza vaccine, as described in Table 2 above, 35% of pregnant women, as diagnosed by a medical professional, received their seasonal influenza vaccine from 1 September 2022 to 28 February 2023 in England.
Marriage and civil partnership
There is no current evidence that these provisions to enable the influenza and COVID-19 vaccination campaigns in the UK will have a greater or lesser impact depending on marital and partnership status.
What the public consultation told us
The majority of respondents (65%) told us they did not think the proposals risked impacting people differently with reference to their protected characteristics. Many respondents told us they were not aware of any adverse impacts relating to use of these regulations to date.
Conversely, several respondents highlighted that COVID-19 can have a disproportionate impact on those with certain protected characteristics (for example, age and disability) and that, consequently, ensuring that we have effective vaccination programmes was crucial to mitigate against inequalities in health outcomes.
Respondents commented that the regulations reduced barriers to access for those with protected characteristics. In particular, the extended workforce was considered by respondents to have played a key role in increasing uptake among vulnerable or harder-to-reach individuals - either by reducing physical barriers to access or by contributing to building trust in communities.
Some respondents told us that the proposed amendments would have a positive impact on inclusivity in the workforce and for patients. In particular, the national protocol model supports career development for those in lower NHS bands, where data shows there is more diversity in the workforce. Furthermore, data was cited showing that members of the public are more likely to take up healthcare interventions when their healthcare professionals reflect the local population.
13% of respondents believed the proposals did risk impacting people differently - however, the comments received predominantly related to concerns around general health inequalities linked to protected characteristics, rather than in relation to the impact of the specific proposals in this consultation.
18% of respondents told us they did not know if the proposals risked impacting people differently with reference to their protected characteristics.
Impacts of COVID-19 and influenza on those with protected characteristics
The regulations under consideration provide a range of general positive impacts to all protected characteristics.
Firstly, they support at-risk individuals across the different protected characteristics to access the latest COVID-19 and seasonal influenza vaccinations as quickly and early as possible through the continued effective roll-out of both vaccination programmes.
Secondly, while some provisions are aimed at scale, the regulations enable the flexibility for the vaccination workforce to provide more bespoke services that target smaller groups. Through outreach vaccination services, which are usually made up of unregistered healthcare workers, the workforce was able to increase uptake - particularly among those in deprived communities where ethnic minority groups tend to be concentrated.
- mobile services
- walk-in clinics
- clinics for specific groups (such as women)
- working with community champions
- using faith buildings, such as mosques
- targeted communications
If the regulations are not extended, NHS England has advised that registered healthcare workers would not make up the shortfall. As a result, the NHS will become more limited in the way in which the vaccines can be delivered to increase the uptake in groups where current uptake is low - particularly for underserved and marginalised groups, or groups where vaccine hesitancy may be stronger.
The regulations also provide additional positive impacts to specific protected characteristics:
Age
Individuals of an older age are at higher risk of severe disease from both COVID-19 and Influenza, and this is reflected in eligibility in current campaigns.
The regulations facilitate quick delivery and administration of the latest vaccines to older adults in a range of settings, including in care homes, thereby reducing the need for travel, and increasing the likelihood that vaccines will be delivered by healthcare workers who are already known and trusted by individuals.
Disability
There is a strong correlation between disability and eligibility for COVID-19 and influenza vaccination. The regulations enable quick and easy delivery of vaccines to disabled individuals, and provide the ability to deliver services specifically designed to encourage people with learning disabilities to get the vaccine.
While age and disability are over-represented in eligible groups in the current COVID-19 campaign, future eligibility is subject to change in response to potential changes in the epidemiological risk linked to new variants. Lessons learned from previous waves of COVID-19 and influenza therefore remain important when considering potential impacts on groups with protected characteristics, and the associated benefits of maintaining a wide vaccination workforce and flexibility in the delivery system.
Lessons learned from the COVID-19 vaccination programme
In February 2022, the National Audit Office (NAO) published its evaluation of the government’s COVID-19 vaccine programme, focusing on events up to the end of October 2021 and assessing whether the programme was well placed to meet its objectives in full.
The report determines the vaccine programme met stretched and unprecedented targets to offer 2 doses of COVID-19 vaccine to most adults in a short space of time by October 2021, delivering 6 times the number in the previous annual influenza vaccine programme.
It also acknowledges that the programme recognised the need for a range of approaches to address low uptake, including:
- campaigns to increase confidence in safety
- targeted materials for different communities
- different routes to get vaccinated
- partnerships with community organisations
NAO’s local case studies were positive about the contribution of unregistered healthcare workers and volunteers, though some did report issues with staffing and recording consent. These issues have not been raised in subsequent engagement with stakeholders.
Driving vaccine uptake and protecting the NHS
The NHS has remained committed to driving vaccine uptake for COVID-19 and influenza throughout each successive vaccine campaign, with a hyper-localised approach being taken to ensure that those from protected characteristic groups, who are at higher risk of severe illness, continue to be effectively targeted for vaccination. It has acted on lessons learned and approaches taken have included activities, such as providing mobile services to get vaccines out to communities, and working with local community representatives to promote and deliver vaccination.
For these activities, the continued use of R3A, R19 and R247A has been essential. Across the UK, future NHS vaccination strategies have emphasised a continued commitment to prioritise equity of access and reduce inequalities in uptake for both COVID-19 and influenza vaccinations going forward. Encouraging uptake of COVID-19 and influenza vaccinations among eligible groups also reduces the burden on NHS services by decreasing the probability of at-risk individuals experiencing severe disease and requiring hospitalisation.
In addition to the direct benefits for at-risk individuals, these regulations help to protect wider capacity in the NHS to the benefit of all service users, including those with protected characteristics.
At the height of the COVID-19 pandemic, these regulations enabled safe and rapid vaccination of health and social care workers with minimum disruption to the provision of other services. Maintaining an expanded vaccination workforce and flexibility in the delivery system is therefore a key factor in helping to protect the health system - both from current pressures from COVID-19 and influenza, and in terms of being prepared for any potential increased burden in the event of new variants of concern.
Conclusion
In summary, the proposed changes to the regulations are a means of maintaining current delivery approaches to COVID-19 and influenza vaccines to support future vaccination campaigns. They are an intrinsic part of the national vaccination programmes and support efforts to target areas of low vaccine uptake or high infection.
It is likely that, without the provisions, the NHS would not have been able to deliver such successful campaigns reaching areas of need.
The NHS has used the full range of options available to it under the HMRs so that it can match available vaccinator staff with public demand and vaccine availability. Across the UK, the devolved administrations have emphasised the instrumental role these regulations have played (and continue to play) in achieving safe and rapid delivery of vaccines, and supporting equity of access for underserved communities (many of whom have protected characteristics).
The NHS has been able to safely vaccinate staff and deliver the vaccination campaigns, and do so with minimal disruption to normal GP and hospital services, using these provisions. By helping to achieve high vaccination coverage across at-risk groups, these regulations have also contributed to reducing the overall burden on the NHS to the benefit of all service users.
As set out above, in the recent public consultation on the proposed amendments to R3A, R19 and R247A, the majority of respondents believed the regulations did not disproportionately impact individuals with protected characteristics. Conversely, many respondents told us that these regulations helped to mitigate that risk by reducing barriers to access for at-risk individuals, many of whom have protected characteristics.
Officials have considered the implications in relation to the proposals to amend R247A and extend R3A and R19 of the HMRs to continue to enable the safe and efficient roll-out of COVID-19 and influenza vaccinations for each of the following 3 equality objectives:
- eliminate discrimination, harassment, victimisation and any other conduct that is prohibited by or under this act
- advance equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it
- foster good relations between persons who share a relevant protected characteristic and persons who do not share it
The regulations under consideration have played a central role in achieving the success of the COVID-19 and influenza vaccination programmes in recent years. Therefore, there currently remains a clear need to maintain these capabilities.
Reducing the prevalence of these illnesses is of great benefit to UK patients and the NHS. As both illnesses disproportionately impact negatively on people with protected characteristics, maintaining a regulatory framework that safely and efficiently supports these vaccination programmes is also of particular benefit to these groups.
Our analysis is that, on balance, there would be greater risk involved in failing to make these regulatory changes (to amend R247A and extend R3A and R19) than to do so. This view was endorsed by the majority of the respondents to the consultation.