The Act lead to centralisation of vaccination co-ordination, with London disproportionately affected. It saw a 36 times increase in the number of patients per Immunisation Lead, with one person accountable for the flu vaccination across the capital. This increase, the largest by far in England, left one person responsible for 2,227,232 eligible patients across 2,186 practices (in comparison, NHS England South West and NHS England North West had factor increases of 7.)

Since the Act came in, the gap between England flu vaccination rates and those in London grew from 1.8% to 6.2% (2011 to 2019/20).  Under two-thirds of those aged 65 and over receive the flu vaccination in London, compared to 74% in Greater Manchester.

The report makes two key proposals, both reflecting the principle recognised by NHS England and Improvement that decisions taken closer to the communities they affect lead to better outcomes:

  • A review of where strategic responsibility for improving immunisation coverage sits, bringing commissioning to a more local level.
  • NHS England and Improvement (NHSEI) should establish local immunisation coordinator roles, to drive coordination and uptake. These local coordinators would act as ‘on-the-ground’ local champions for vaccine uptake, coordinating providers to work more effectively with their eligible patients, and providing a resource for the most up to date information on effective interventions

The 2020-21 season has seen significant expansion in eligibility for the flu vaccine, and thanks to the incredible efforts of NHS and Public Health England uptake rates are higher in all eligible groups than they were at the same point last season. There has been a particularly notable boost for over 65s, among whom a record 80.2% have been vaccinated so far – nearly 10% higher than last year, and well above the 75% WHO target.

However, the new report argues, this year’s laudable successes should not distract us from longstanding weaknesses within the vaccination framework – weaknesses which disproportionately impact vaccine uptake in the capital. Even in this successful year for flu vaccination, London lags behind with uptake at 70.6% while all other regions have exceeded the 75% WHO target.

The report also explores other factors behind London’s low rates, finding that:

  • The gap in reported vaccination rates between rich and poor is wider in London than other major urban areas in England. In London, the city with the highest levels of relative poverty in the country, our research found 58% of eligible people from households earning below £20,000 were vaccinated, compared to 93% for patients from households earning above £80,000**
  • Greater London has a higher proportion of patients getting the vaccine in a pharmacy setting than other major cities. Due to concerns about underreporting of data from pharmacies, this may contribute to artificially low headline rates in the capital.


Christina Marriott, Chief Executive of RSPH, commented:

“With high levels of deprivation and ethnic diversity, London is home to many groups that are time and again let down by our health system. But the story of boroughs like Tower Hamlets, with the highest uptake rates in one of the most deprived populations in the capital, tell us things need not be this way.

“We of course must celebrate and applaud the tremendous efforts of NHS staff in delivering more flu vaccination than ever in this most crucial of years. However, we also need to think beyond this season, and recognise that many of our most vulnerable communities are being failed by an overstretched system, particularly in London.

“To end this cycle, the coordination and commissioning of vaccination need to be brought closer to the communities they serve, and we hope this report sets out a path to doing so.”

Dr Doug Brown, Chief Executive of the British Society for Immunology, said:

“Today’s publication of the Royal Society for Public Health report on London’s low flu vaccination rates, Mind the Gap, shows a concerning downward trend in flu vaccination uptake in Greater London, highlighting the urgent need to address the numerous barriers to improving coverage.

“Flu vaccination rates in London have substantially decreased since the 2012 public health reforms, falling behind more rapidly than the national average and widening the gap between London and England. Without high levels of vaccination coverage, diseases have the potential to spread within our communities putting lives at risk.

“We support the recommendation made by the Royal Society for Public Health calling for NHS England and NHS Improvement to establish the local immunisation coordinator roles to act as ‘on the ground’ champions for vaccination. This, coupled with increased accessibility of services, community outreach and funding, will ensure we have a strong vaccination framework beyond the pandemic.”

David Sinclair, Director of the International Longevity Centre UK, commented:

"It is brilliant that we have seen such high flu vaccination rates across the country this year. But we can’t afford to leave anyone behind. We must ensure that the flu vaccine benefits all and focus time and effort to reach the most excluded.

“As we are witnessing with the rapid delivery of the COVID-19 vaccine, it’s clear that some groups of the population are less likely than others to take the jab. As RSPH have already highlighted, people from minority ethnic backgrounds are less likely than other groups to say they will take the vaccine if offered.

“It is imperative that, as the Government reviews the future of the NHS, they consider how commissioning can ensure preventative treatments, such as vaccinations, best reach the people who could benefit from them most.”

* The activity presented in this report has been sponsored by Sanofi. Sanofi did not have editorial input and is not responsible for the content or opinions expressed as part of this report.

** Survey conducted between 6/12/19 and 22/12/19 through Toluna, and included 888 residents of major English cities, all eligible for flu vaccination.