Vaccination systems under pressure: what the UK COVID-19 Inquiry teaches us about preparedness

Urgent action is required to close gaps in routine programme delivery and strengthen pandemic preparedness. Synthesising pandemic learning from the United Kingdom (UK) COVID-19 Inquiry demonstrates that the potential of vaccine innovation to save lives will be undermined without robust and adaptable routine delivery strategies.

UK COVID-19 Inquiry

Launched in June 2022, the COVID-19 Inquiry will result in recommendations to inform preparedness plans – which UK nations are encouraged but not obligated to accept. A monitoring process drives preparedness by assigning recommendations to stakeholders and requiring them to publish ‘the steps they will take in response and the timetable for doing so’. ¹ Oversight matters because issues raised during the COVID-19 vaccine roll-out were consistent with those identified during the Hine Review of the 2009 H1N1 influenza pandemic response, ² raising questions about the application of past recommendations.

The COVID-19 Inquiry examined vaccines and immunotherapeutics in January 2025. Commentators have since drawn attention to three issues: fair compensation for vaccine damage, public reluctance to vaccinate and the UK’s limited vaccine manufacturing capacity.^3,4 Whilst they are important, the foundation for equitable vaccine access must not be overlooked: a robust routine delivery system that can be harnessed during outbreaks and pandemics.

We wrote an expert report for the UK COVID-19 Inquiry on vaccine delivery systems and disparities in coverage, offering a forensic analysis of approaches that limited and enabled vaccines to be within equitable reach of every eligible individual. Advancing immunisation system preparedness will require a pragmatic approach due to fiscal constraints and the abolition of NHS England. ⁵ We outline three interlinked strategies to harness learning from the Inquiry: (i) identifying underserved or vulnerable cohorts and triaging priority cohorts to appropriate delivery points; (ii) expanding the vaccination workforce and (iii) providing vaccine communication training to all frontline NHS workers who engage with the public to confidently reinforce vaccine recommendations. ⁶ Addressing these priorities will help bolster the delivery of routine child and adolescent programmes, strengthening the way people engage with the immunisation system across their lifecourse.

Efficiently identifying and triaging vulnerable cohorts

A system of cohort prioritisation requires vulnerable groups to be identified efficiently and triaged to the most suitable delivery point. Identifying vaccine-eligible individuals remains a major challenge in routine immunisation, requiring the integration of demographic and health data. Progress on UK-wide data synthesis is needed for pandemic preparedness efforts. This will require attention to the type and quality of data recorded (e.g. more systematic recording of disability codes), better integration of health records and alignment of data recording across UK nations to support consistent delivery. ⁷ Decision-making during pandemic responses evolves rapidly and relies on accurate data and information.

Data monitoring can help understand factors affecting equitable coverage. Routine immunisation data is limited by a lack of accurate coverage for underserved communities, such as Charedi Jewish or Roma, Gypsy and Traveller families, who have experienced successive disease outbreaks. Generalised ethnic identifiers (e.g. ‘white other’) prevent primary care teams from having a granular understanding of undervaccinated cohorts. There is a need to improve data monitoring in primary care records to enhance the granularity of information on ethnicity and protected characteristics such as disability. Such data help allocate limited resources equitably to tailored delivery pathways and monitor improvements in coverage.

Disabled people did not experience the same levels of vaccine inequity during the COVID-19 pandemic observed in ethnic minorities. ⁸ Yet, some disabled groups were not efficiently identifiable, notably people with learning disabilities who were designated a priority cohort by JCVI.^5,8 Registers to support the identification of people with learning disabilities are not consistently operationalised across UK nations, limiting the management of appointment booking and related triage to appropriate delivery pathways. Although there may be operational benefits to consistent identification processes for this cohort, we recommend that public health agencies in the devolved nations consult with disabled people’s organisations to develop similar registers.

Expanding the vaccination workforce

Rapidly identifying and inviting priority cohorts requires a sizeable and sustainable workforce of trained vaccinators. The ability to mobilise this workforce is key for pandemic preparedness, and there is a case for delegating vaccination responsibilities to a wider range of health professionals within primary and secondary care. NHS England and UK Health Security Agency (UKHSA) are assessing and evaluating the effectiveness of commissioning health visiting teams and community pharmacies to deliver routine vaccination programmes to redress declining coverage. This work will provide insights on how different cadres of vaccinators could be deployed in pandemic responses.

Black Caribbean adults were least likely to receive two doses of COVID-19 vaccination through to June 2022, including those in the highest priority age cohorts most at risk of death. ⁵ This group was also least likely to receive an influenza vaccine across eligible cohorts in 2024–2025, including those under 65 at risk, over 65 and pregnant women, indicating that inequity is persistent across the lifecourse. ⁹ Expanding routine vaccine delivery in non-primary care settings may benefit at-risk and child cohorts attending specialist services. In secondary care, nurses and physicians managing patients with long-term conditions are well placed to offer seasonal influenza vaccines opportunistically – but this is not standard practice. A business-as-usual approach to offering influenza vaccines in secondary care would enable expertise and touchpoints to be drawn upon in emergency scenarios.

The use of mass COVID-19 vaccination sites (MVS) was a key difference to the H1N1 vaccine response, facilitating the vaccination of large numbers at pace. However, they were used less by populations with lower uptake of routine vaccines. MVS were not always accessible for wheelchair users, and people living in deprived areas incurred higher transportation costs. MVS were less equipped to facilitate equitable access for underserved groups, who were more likely to engage with tailored, or outreach delivery pathways developed in collaboration with their communities. Long-standing data sharing arrangements between the Home Office and NHS England obstructed access for people with insecure immigration status, who felt safer using walk-in vaccination services in food banks or community settings where NHS numbers or identification were not required.

Planning delivery approaches by defined areas can offer multiple pathways for vaccination to increase convenience and confidence. Effective COVID-19 delivery models for disabled people included adapting clinics to be sensory-sensitive or offering extended appointment times. Such inclusion strategies have been described as ‘exceptions not the norm’, ¹⁰ and there are limited understandings of the barriers that disabled adults experience in accessing routine immunisations. People considered ‘clinically extremely vulnerable’ faced avoidable barriers when directed to busy delivery points with increased potential of viral exposure. An area approach would help signpost clinically extremely vulnerable or disabled people to primary care settings operating ‘quieter hours’ and longer appointment times. Place-based strategies should enable primary care teams to train and supervise volunteer vaccinators from trusted community organisations, or experienced healthcare assistants, to counsel and vaccinate in their communities.

Vaccination communication training for healthcare professionals

An expanded immunisation workforce will require consistent access to communication training. The UKHSA has produced guidance for minimum standards and core curriculum for vaccination training for staff with a role in delivering vaccination programmes in England, especially administering vaccines. ¹¹ Responsibility for providing immunisation training to healthcare practitioners is delegated to employing organisations (GP surgeries or Trusts) in England, which produces inconsistencies. There is increasing recognition across UK public health agencies that the wider healthcare workforce plays a key supporting role in vaccine programme delivery. Administrators in primary care settings are often involved in call/recall and field patients’ calls to book vaccine appointments, but their training opportunities in the principles of vaccination and vaccine communication remains sparse. Training frontline staff to confidently recommend vaccination can help make every contact count, while enabling administrators to defer clinical questions to nurses. Annual vaccine communication update training would improve consistency in recommendations across patient touchpoints, and national agencies should take responsibility for overseeing system-wide training.

Implications for investing in a state of readiness

The UK Government invested £120 million in vaccine development between 2016 and 2021 as part of preparedness efforts. ¹² However, no proportional commitment was made to strengthen universal vaccine programme delivery systems and avoid foreseeable issues in coverage. To meet the ambition of having vaccines available for deployment in the first 100 days of a pandemic, ¹² immunisation systems need to be in a state of readiness to be pivoted. The nation’s public health infrastructure had been eroded by austerity.^13,14 Repeated health system reforms have fragmented immunisation systems undermining efficiency and resilience. ⁶ The abolition of Public Health England during the COVID-19 pandemic brought further disruption, ¹⁵ highlighting the need for stable immunisation systems that can rapidly adapt during pandemics.

Plans to dismantle NHS England and reduce budgets allocated to Integrated Care Boards, responsible for commissioning area and place-based service delivery, are likely to jeopardise vaccine coverage recovery. ⁶ We caution against measures that will undermine the goal of strengthening routine immunisation delivery by cutting key support roles and threatening crucial engagement work with underserved communities. The onus is on policymakers to explain how reduced public health investment can be reconciled with efforts to put the UK on a stronger footing for pandemic preparedness.

Conclusion and recommendations

Gaps in routine programme delivery will prevent efficient and equitable delivery of vaccinations in a pandemic, making routine delivery systems the canary in the coalmine for preparedness. For progress to be feasible and measurable, we urge UK public health agencies to prioritise efforts to identify and deliver vaccines, engage proactively with underserved communities and train healthcare providers across the sector to offer vaccination with confidence. The COVID-19 Inquiry offers a catalyst for the decisive action needed to strengthen routine immunisation services ahead of the next public health emergency.