By Daisy Copping (BSc Economics), Amrish Patel and Clare Purser (Bsc Economics & Finance)
Do enough social care staff get vaccinated?
The COVID pandemic has shown how vulnerable the social care sector is to infectious disease, particularly care homes. As winter approaches the NHS and social care sector will likely face the dual threat of COVID and seasonal flu. Dr Suzanna McDonald, National Programme Lead for Influenza, Public Health England (PHE) stated that: The best defence against flu is the vaccine and it’s not too late to protect yourself and your family (PHE 2019).
Flu can cause serious illness and even death in vulnerable people due to underlying health conditions and weak immune systems. The estimated number of deaths attributable to flu range from 4,000 per year to 14,000 per year (PHE 2019).
Randomised controlled trial evidence shows that vaccinating those who are in direct contact with vulnerable people such as front-line health and social care staff can reduce the risk of flu transmission to their vulnerable patients where attack rates have been estimated in the range of 20-40% (Haywood 2006; NICE 2020).
The flu vaccine has been free for all nursing and care home staff since the 2017/18 flu season (PHE 2018). Despite this, in March 2018, The House of Commons Science and Technology Committee reviewed the findings of a study of care home staff vaccination rates which showed “huge variability, with the best [uptake] at 25%” (Thornton 2018). The figure was described by Norman Lamb, the committee’s chair as outrageous and that the government needs to be aiming for full vaccination coverage amongst care home staff to ensure residents are protected (Flu vaccination programme 2018). There is no centralised collection of data, so the current staff vaccination rate is unknown, but it thought to be well under the World Health Organisation’s target of 75%.
So what can economics tell us about why so few social care staff get vaccinated? Too much for one blog post! We make no attempt to give an exhaustive account here, but will focus on a few specific explanations instead.
Do employers have strong incentives to encourage vaccination?
Employers are generally critical in influencing staff behaviour. Perhaps social care employers have no incentive to encourage vaccination? This turns out not to be the case: Employers can make significant cost savings if staff get vaccinated.
The National Institute for Health and Care Excellence (NICE) found that the main cost saving is the reduced need for expensive temporary agency workers covering staff flu absences. On average, staff take 2.5 flu sick days, costing employers £487.50 (PHE 2018).
Increasing flu vaccine uptake in social care staff can thus deliver enormous savings for employers. South Gloucestershire Council have developed a flu vaccination calculator help estimate how much can be saved. Looking at a sectoral level, we input:
The number of independent social care jobs = 1.52 million (Skills for Care 2019).
- The daily cost of each worker = £195 (Unit costs of Health and Social Care Staff Study 2019).
- Vaccination rate = 25% (PHE 2018; Surveillance of Influenzas in Northern Ireland 2018).
The net total saving for the independent care sector from staff flu vaccination is approximately £7 million.
In theory then, employers have a huge incentive to encourage vaccination. Of course employers, like everyone, make decisions on the basis of perceived utility consequences rather than actual utility consequences (e.g. Kahneman and Thaler 2006).
In an underfunded sector, where social care employer struggle to stay afloat are overburdened with bureaucracy and are increasingly dealing with complex patient health needs (Orellana et al. 2015) encouraging staff flu vaccination is only one of the many responsibilities employers have. Possibly one that is perceived as less important than others.
Do social care staff have enough incentive to get vaccinated?
If vaccination is free for social care staff, surely they have a good incentive to get vaccinated? Maybe.
As with other decisions, vaccination choice is made on the basis of perceived costs and benefits. While vaccination is cost-free in monetary terms, there are many other costs: the time costs associated with going to a GP/pharmacist or the costs associated with the risk of side-effects. Indeed, from a personal perspective, the perceived benefits of flu vaccination for staff may be quite low. For a fit and healthy, 20 year old care support worker with no underlying health conditions, avoiding a short bout of flu may have a very small benefit. So the perceived private cost may indeed outweigh the perceived private benefit leading to non-vaccination.
Of course vaccination of social care staff has large positive externalities, that is the patients that staff care for potentially derive huge health benefits from avoiding flu infection. To some extent then, this is a classic case of the market failure associated with a good with a positive externality. Where staff internalise the externality due to a feeling of professional duty or responsibility to patients, there is no market failure; otherwise we see vaccination rates lower than levels that which would be socially optimal.
Herd immunity as a public good?
Even for staff who internalise the externality to some extent, the herd immunity that vaccination aims to create leads to complex “strategic incentives”. That is, if the set of staff (the herd) needs to achieve a certain vaccination rate (to achieve immunity), given that there is a private cost of vaccination, you would rather others’ get vaccinated – i.e. there is an incentive to free-ride.
Herd immunity is a public good in the sense that you cannot stop someone from benefiting from this (non-excludability) and one person’s benefit from the virus not spreading is not at the cost of another person’s benefit (non-rivalty).
Trying to analyse the strategic incentives staff have to get vaccinated using real world data is complicated. Researchers thus design artificial experimental games which simulate the real world vaccination choice.
A study by Ibuka et al. (2014) represented the population with 8-10 participants and the flu season by the 24 choice-rounds in the experiment. In each round, participants decided independently and simultaneously whether to receive a hypothetical flu vaccine. They each received 2000 points which could be spent on receiving a vaccination or kept; points were deducted if participants were infected. The probability of infection depended on: own vaccination status; others’ vaccination decisions; and their simulated demographic status (elderly or young, with the former losing more points from infection).
They found that the estimated probability of a participant getting vaccinated decreased by 19 percentage points as the proportion of vaccination in the previous round increased from 0 to 1. Put differently, there is more free-riding when vaccination rates are higher in previous rounds.
Does time play a role in vaccination choice?
Suppose that a care home worker does not have large free-riding incentives and that the benefits of vaccination are a little higher than the costs. Surely they would get vaccinated right? Not necessarily – the influence of time on preferences may work against vaccination.
Behavioural economists have long understood that we perceive £1 today as worth considerably more than £1 tomorrow (even if there is zero inflation). This is the idea of present bias or hyperbolic discounting (Ainslie and Haslam 1992). In the vaccination context, we are talking about incurring costs today (e.g. effort to go to pharmacy) for a benefit in the future (Nuscheler and Roeder 2016). So if the benefit is only a little higher than the cost, hyperbolic discounting would make the cost feel larger than the benefit, leading to non-vaccination.
The need for research
While we know lots about flu vaccination in general (NICE evidence review), surprisingly little is known about the flu vaccination behaviour of those caring for vulnerable people in social care contexts. Simple data such as the number of staff getting vaccinated is not routinely collected, let alone more detailed information on why staff do not get vaccinated.
To fill this research gap, we are doing a survey to try and understand current vaccination rates among social care staff and some of the barriers to vaccination. Survey link: https://bit.ly/30cIc9S
While there is a long way to go to reach the WHO’s 75% vaccination rate target, this research will be one piece in the puzzle that we need to solve to reach the target. The lives of people in care depend on it.
References
- Ainslie, G. and N. Haslam (1992) Hyperbolic Discounting. In G. Lowenstein and J. Elster (eds.) Choice over time. Russell Sage Foundation.
- Demirci, E.Z. and Erkip, N.K. (2019). Designing an intervention scheme for vaccine market: a bilevel programming approach. Flexible Services and Manufacturing Journal, 32(2), pp.453–485.
- Flu vaccination programme in England Ninth Report of Session 2017-19 Report, together with formal minutes relating to the report. (2018). [online] Available at: https://publications.parliament.uk/pa/cm201719/cmselect/cmsctech/853/853.pdf [Accessed 1 Aug. 2020].
- Government Response to the House of Commons Science and Technology Committee Report on Flu Vaccination in England: Ninth Report of Session 2017-19. (2019). [online] Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/769777/government-response-to-report-on-flu-vaccination-in-england.pdf.
- Ibuka, Y., Li, M., Vietri, J., Chapman, G.B. and Galvani, A.P. (2014). Free-Riding Behavior in Vaccination Decisions: An Experimental Study. PLoS ONE, 9(1): 87164
- Kahneman, D. and R. H. Thaler (2006) “Anomolies: Utility maximization and experienced utility” Journal of Economic Perspectives 20(1): 221-234.
- Nice.org.uk. (2020). Quality statement 4: Vaccinating health and social care staff | Flu vaccination: increasing uptake | Quality standards | NICE. [online] Available at: https://www.nice.org.uk/guidance/qs190/chapter/Quality-statement-4-Vaccinating-health-and-social-care-staff [Accessed 19 Aug. 2020].
- Nice.org.uk. 2020. The Committee’s Discussion | Flu Vaccination: Increasing Uptake | Guidance | NICE. [online] Available at: <https://www.nice.org.uk/guidance/ng103/chapter/the-committees-discussion#employers-of-health-and-social-care-staff-2> [Accessed 19 September 2020].
- NHS England (n.d.). NHS England » Social care: guidance for workforce flu vaccination. [online] Available at: https://www.england.nhs.uk/increasing-health-and-social-care-worker-flu-vaccinations/social-care/ [Accessed 1 Aug. 2020].
- Nuscheler, R. and K. Roeder (2016) “To vaccinate or to procrastinate? That is the prevention question” Health Economics 25(12): 1560-1581.
- Orellana, K., Manthorpe, J. and J. Moriarty (2015) “What do we know about care home managers? Findings of a scoping review” Health and Social Care in the Community 25(2): 1-12.
- Public Health England (2019). UK flu levels according to PHE statistics: 2019 to 2020. [online] GOV.UK. Available at: https://www.gov.uk/government/news/uk-flu-levels-according-to-phe-statistics-2019-to-2020.
- Public Health England, (2018). Flu and flu vaccination 2019/20: A toolkit for care homes. London: Public Health England, pp.1–21.
- Skills for care (2019.). The state of the adult social care sector and workforce in England. [online] Available at: https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx.
- Surveillance of influenza in Northern Ireland. (2018). [online] Available at: https://www.publichealth.hscni.net/sites/default/files/2019-08/Northern%20Ireland%20Influenza%20Surveillance%20Report%202018-19.pdf [Accessed 1 Aug. 2020].
- Thornton, J. (2018). MPs slam “outrageous” 25% uptake of flu vaccine among social care staff. BMJ, p.k4423.
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