Is flu vaccination opt-out feasible? Evidence from vaccination programme implementers and managers in the English National Health Service

Background: In 2018/19, English NHS trusts (NHSTs) implemented an 'opt-out' policy for seasonal flu vaccination in frontline healthcare workers (HCWs). HCWs declining the vaccination were asked to sign an opt-out form and provide a reason for their decision. In addition, HCWs working in higher risk hospital environments (e.g. oncology) were asked to inform their manager about their declination decision. The policy aimed to provide greater insight into reasons for vaccination decline and information from HCWs in higher risk areas was intended for use in considering HCW redeployment. This study investigated the feasibility, acceptability, and perceived value of the policy during the 2018/19 flu vaccination season.

Methods: We conducted semi-structured interviews across 9 NHSTs in England with different levels of HCW flu vaccination uptake in 2017/18. We interviewed 30 vaccination programme implementers and 27 managers.

Findings: The purpose of the policy was poorly understood, and interviewees did not know how data on decliners was being used. Most NHSTs tried to collect the personal details of decliners and, in some instances, these were recorded in Electronic Staff Records and reported to line-managers for action. This created strain on employer-employee relationships, leading to decliners refusing to complete opt-out forms and some vaccinators not implementing the policy. None of the NHSTs had a redeployment policy for decliners, arguing that this was impractical due to strain on staffing levels.

Conclusion: A flu-vaccination opt-out approach for HCWs did not appear acceptable in our sampled NHSTs, due to a lack of clear messaging about its purpose and complicated implementation. To promote an opt-out approach effectively, there needs to be clear communication of its purpose, which should be to explore reasons for decline rather than identify and 'push' decliners to vaccinate, so as not to damage staff relationships. NHSTs should involve their workforce in developing flu vaccination approaches.