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A vital injection

Developing COVID-19 vaccines in less than a year showed the extraordinary capabilities of modern medical science. The next challenge? Getting those shots into tens of millions of arms. Digital technology is playing a crucial role.

Person with a rolled-up sleeve getting vaccinated.

Adrian Stanbury recalls, with some understatement, that the COVID-19 vaccination programme was “looming very large on the national radar” in October 2020.

In fact, it is fair to say that no single medical intervention has ever been so universally and so urgently awaited. The health service needed the vaccines, the economy needed them and tens of millions of people knew they needed a jab to protect themselves and their loved ones.

“Essentially,” says Stanbury, the director of technology and data for the programme, “The NHS was trying to put in place a system that catered for the administration of a vaccine twice, to everyone in England, as quickly and as safely as possible, while upholding standards of clinical safety and usability in an extremely tight timeframe.”

“I don’t think anyone would walk into a programme of this importance feeling 100% prepared,” he says. “It was daunting because it wasn’t crystal clear in the early days what some of the issues were or what needed to be sorted out.”

We were working with vaccination centres that didn’t yet exist.

The NHS vaccination programme is the biggest in health service history. It brings a huge number of organisations together to act as one team, including NHS England and NHS Improvement, the Department of Health and Social Care, Public Health England, NHSX, NHS Digital, the National Immunisation Management Service run by NHS South, Central and West, and a constellation of partners across the NHS, voluntary and private sectors.

NHS Digital leads the technology and data workstream, an expansive portfolio that underpins every step of the vaccination process, enabling the system to: identify and prioritise people who are eligible for vaccination, invite or remind them to book their appointments, record and organise those bookings, and then register the jabs that are administered so that data can flow into patients’ individual records and national reporting systems. That data has been crucial to monitoring vaccine effectiveness and safety and to spotting variations in uptake. GPs, for example, can see a dashboard about uptake in the community they serve, allowing them to address issues in their area.

 

The results – of this technical work but also of the huge, coordinated effort across the NHS, including grappling with major logistical, workforce, communications and clinical challenges – has been one of the most successful vaccination programmes in the world. By 17 June all adults in England had been invited to get vaccinated and by the end of August 2021, there had been some 76 million vaccinations given in England. Ultimately, 100 million vaccinations are expected to be administered.

We didn’t have years; we had days and the risks of delay were obvious.

A race against time

James Spirit, Head of Product Management for the National Booking Service, says that some of the biggest challenges in the early days were simply the result of breaking new ground. With the exception of the COVID-19 testing programme, which faced similar challenges, nobody had ever set up a universal service for England’s adult population in the timescales that were being asked.

“We were working with vaccination centres that didn’t yet exist. We didn’t know what they would look like, or how they would operate. We didn’t know how they would get their vaccine supply. We had to work with significant levels of uncertainty.”

From the start, the pressure was on to get systems set up quickly. A key data flow, for example, was recording ‘adverse reactions’ to the vaccinations such as fatigue, headaches or fever. This data was crucial so that the Medicines and Healthcare products Regulatory Agency (MHRA), which manages the licensing and approval of vaccines, could collect and keep track of information about suspected safety concerns of incidents concerning the vaccines themselves.  So there was enormous pressure on NHS Digital to get all the point-of-care systems flowing adverse reaction information.

More than 11,000 community pharmacies, 6,500 gp practices, 2,000 vaccination sites, 200 NHS trusts, 100 prisons and 130 Ministry of Defence settings are safely and securely sharing data through the vaccination programme using more than 30 different IT systems

“I don’t think people realise how complicated it is to get a single data flow going,” says Vaccines Programme Manager Tom Burnett. “Once we had the data, we had to process it to make sure it matched NHS numbers. If there wasn’t a match, we had to do data-quality assessments to see if we could add one.”

That data was then flowed through to the National Immunisation Management System (NIMS), provided by one of our partners, NHS South, Central and West, as part of the National Immunisation Management Service. This system supported the programme by holding vaccination records, demographics and inviting  more than 60 million people to book a vaccination. “That’s just one flow of many,” says Burnett. “There are so many different endpoints that need the data and also produce the data. You’ve also got prisons, the Ministry of Defence and schools to name just 3. We’ve been knocking down these types of barriers since September,” he says.

And, of course, nothing quite goes to plan. Spirit recalls one vaccination site in the North-East of England that didn’t appear to be getting any bookings after the National Booking Service was switched on.

“When users tried to search for that site, it wasn’t there. It turned out that the way the site’s GPS coordinates had been typed in put it in the middle of the North Sea, rather than Newcastle. Fortunately, it was something we were able to fix quickly.”

Another small site with capacity for about 150 appointments a day accidentally published tens of thousands of appointments for its first week of operations.

By the time the mistake was spotted and fixed, it had about 5,000 appointments booked over just a few days. The local team stepped up, brought in more people, and vaccinated everyone without having to cancel a single appointment.

40 million appointments booked via the national booking service and on the busiest day an average of 750 appointments were booked per minute


Teamwork

It was that kind of spirit, throughout the local and national teams working on vaccinations, that Stanbury says helped the programme achieve the improbable.

“You didn’t have to ask these teams to do it. They just did it,” he says. “When you hear ‘one team and everyone working to a common purpose,’ it can become a cliché, but it’s absolutely valid in this case,” he says.

“I remember working with a supplier’s comms team at midnight on a Saturday, discussing how we could get messages to GP practices overnight. At no point did anyone say: ‘I’m not really sure I can do that.’ That was the story everywhere.”

Between October 2020 and mid-March 2021, Stanbury says the NHS Digital teams were working flat out. They took one day off: Christmas Day.

“We had a period where everyone was working 70-80 hours a week,” says Burnett, who says it felt like being on a war footing. “All the developers were doing it, the assurance people and the clinical teams.”

“You do question whether you’ve made the right decision,” says Spirit. “You know it’s going to be hard work, stressful and will mean long hours. But there’s also the knowledge that this is possibly the most important thing you’re ever likely to work on.”


A new approach

But hard work has only been part of the story. Burnett says it was quickly apparent that new ways of working and thinking were required: “We were putting things into a live environment that would normally have gone through a much longer-term review process.

We knew we had to work quickly, safely and absolutely respect the privacy of people’s data, but the ‘belt and braces’ approaches that we would have used in normal times were not going to work. We didn’t have years; we had days and the risks of delay were obvious. We had to move away from the old procedures and find new ways to achieve the same ends.

“Put simply,” he says, “there were times when we had to prioritise practicality over technical purism and we made sure clinical experts were involved constantly.”

“When you’re trying to design an end-to-end service and build a product, you do have to accept a certain amount of risk,” says Spirit. “You have to describe your assumptions and articulate the risks, while maintaining the momentum of building the service to the best of your ability. And when things change – as they do constantly – you have to respond. That’s where the value of a multidisciplinary team that’s able to shift its priorities comes in. That was one of the key contributions to our success.”

More than 1,200 local and mass vaccination sites connected to national IT systems


Moving forward

The past year has proved that it is possible to for NHS Digital and its partners to shift from working within multi-year to multi-week timescales when developing national programmes.

“We do need to be a bit careful about what lessons we learn,” says Stanbury. “There was a lot of forgiveness from other teams who accommodated the activities carried out by the vaccines workstream. We also need to realise that many of the things that might seem to slow things down in ‘peacetime’ are actually the measures you put in place to make the best use of scarce resources. We had more license to use what we needed because of the unprecedented speed of delivery, but this isn’t viable under normal circumstances.”

However, it’s clear that ways of working with suppliers have been developed over the past year that are valuable.

“We had a much more collaborative and open way of working during COVID-19,” says Burnett. “Suppliers have been happy to work together and I hope we can carry on doing that in the future.”

Spirit explains: “You have to leave your identity badge at the door. We shouldn’t view what was achieved as coming from a combination of different organisations – it was more a group of people trying to achieve the same goals."

Now that a large majority of adults in England have had at least one dose of a COVID-19 vaccine, Stanbury, Spirit, Burnett and the rest of the team are gearing up for the next phase of the programme and finalising plans to support the NHS with both flu and COVID-19 vaccinations this autumn and winter. This includes things such as enabling eligible groups to book a single-dose ‘booster’ COVID-19 jab in line with guidance from the Joint Committee on Vaccination and Immunisation and ensuring tech systems are set up to support sites to administer both flu and COVID-19 vaccinations at the same time.

Burnett sums up the achievement: “The levels of stress and work involved were huge. People were working from home and trying to fit in home schooling at the same time. It certainly wasn’t the best environment for very long hours. But everyone managed. In fact, they knocked it out of the park.”

Stanbury agrees: “The work is far from over, but I think as we progress we should not be afraid to look back and be really proud of everything we have achieved.”

The data and technology workstream:
  • delivered the National Booking Service on the NHS website
  • set up hundreds of new vaccine centres with national IT infrastructure
  • provides cyber security support across the system
  • creates vaccination data flows to connect the dozens of national and local systems involved
  • ensures the accuracy of vaccination records by providing data quality dashboards and chasing down specific data quality issues
  • developed, in partnership with NHSX, the COVID Pass in the NHS App which allows individuals to prove their vaccine status

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Last edited: 8 September 2021 10:51 am