Covid-19
Vaccination programme

Briefing prepared by Audit Scotland 
September 2021

Key messages
1	The Covid-19 vaccination programme has made excellent progress in vaccinating a large proportion of the adult population. More than 90 per cent of people aged 18 and over have received at least one Covid-19 vaccine. The programme has been effective in reducing the number of people getting severely ill and dying from Covid-19. Vaccines have been delivered in a variety of ways to make it easier for more people to access them, and the level of vaccine wastage has been low. 
2	Engagement with the vaccination programme is lower in some groups of the population. A smaller proportion of younger people, those living in the most deprived areas and people from some ethnic groups have been vaccinated. The Scottish Government is taking action to encourage people to take up the offer of a Covid-19 vaccination. 
3	The Covid-19 vaccination programme is being implemented under uncertain and challenging circumstances. Clinical advice from the Joint Committee on Vaccination and Immunisation (JCVI) continues to evolve and has needed to be implemented quickly. The Scottish Government and NHS boards are responding quickly to new clinical advice and are planning for future stages of the programme. 
4	The Scottish Government has agreed that the UK Government should lead on the purchase and supply of the vaccines on a four nations basis. The Scottish Government and NHS Scotland are responsible for delivering the Covid-19 vaccination programme in Scotland. NHS boards and Health and Social Care Partnerships (HSCPs) have predicted that the programme will cost £223.2 million in 2021/22. The expenditure needed will depend on advice issued by the JCVI, so it could differ substantially from current predicted costs. The Scottish Government has confirmed that vaccination costs will be fully funded for the 2021/22 financial year. 
5	The vaccination programme has relied on temporary staffing to date. The Scottish Government has recognised that a longer-term solution is needed for future phases of the rollout to be sustainable.
6	The delivery of the vaccination programme has been a success so far, with good collaboration, joint working and new digital tools developed at pace. There are opportunities for the Scottish Government to use the learning from this programme to inform the implementation of further stages of the vaccine programme and the wider delivery of NHS services.

 Introduction
1.	The Covid-19 vaccination programme has been a crucial part of the UK and Scottish governments’ responses to the pandemic and has helped to protect Scotland’s population from Covid-19. It is the largest vaccination programme that NHS boards have ever carried out. The vaccines have helped to reduce the incidence of severe illness and death from Covid-19 and have eased pressure on stretched NHS services. The vaccines have also allowed restrictions across Scotland to be lifted more safely, supporting economic recovery. 
2.	The first doses of Covid-19 vaccines in Scotland were administered on 8 December 2020, following the approval of the first Covid-19 vaccine by the Medicines and Healthcare Products Regulatory Agency (MHRA). By September 2021, four vaccines had been approved by the MHRA. These were Pfizer-BioNTech, Oxford-AstraZeneca, Moderna and Janssen. The JCVI has not yet provided guidance on the use of the Janssen vaccine, but the remaining three vaccines are in use (Exhibit 1, page 5).
3.	This briefing paper looks at progress of the Covid-19 vaccination programme to September 2021 and what plans are in place for the next phase of the rollout and for the longer term. We will also report on further progress of the programme in our NHS in Scotland 2021 report, which will be published in early 2022.
4.	We would like to acknowledge the support and assistance provided by the Scottish Government and NHS boards that has enabled us to prepare this 
briefing paper.
5.	This paper is in three sections:
•	Part one (Management of the programme) sets out the aims and objectives of the Covid-19 vaccination programme. It covers how the vaccination programme has been managed, the staffing and infrastructure put in place and costs so far. 
•	Part two (Progress so far) covers the progress of the Covid-19 vaccination programme. It covers how many people have been vaccinated, variation in uptake, and what impact the vaccination programme has had. 
•	Part three (Next steps) sets out the next steps of the programme. It covers how the Scottish Government is preparing to deliver a booster programme from autumn 2021, and the longer-term role of the Covid-19 vaccination programme. 
Management of the programme
The Scottish Government is responsible for the vaccination programme, and has prioritised Covid-19 vaccinations in accordance with JCVI guidance	
6.	The Scottish Government has agreed that the UK Government should lead on the purchase and supply of the vaccines on a four nations basis. The Scottish Government and NHS Scotland are responsible for the management and delivery of the Covid-19 vaccination programme in Scotland. 
7.	Scotland’s allocation of the total supply of vaccines arriving in the UK is based on the Barnett formula. The main factor determining the speed of the first phase of the rollout was the availability of vaccines. As the programme progressed, the Scottish Government made changes to more effectively allocate the available supply of vaccines across Scotland. NHS boards now plan the deployment of vaccines on a weekly basis, based on the expected supply of vaccines. The Scottish Government reviews these plans weekly alongside national modelling of predicted demand to manage the allocation of vaccines. 
8.	The Scottish Government has based its decisions on which groups should be prioritised for receiving Covid-19 vaccinations on advice from the JCVI. This approach has been taken by all four UK nations. 
9.	The JCVI developed nine priority groups for receiving Covid-19 vaccinations based on those who are most at risk from contracting Covid-19 (Appendix). The JCVI recommended that those living in care homes, older people, clinically vulnerable people and patient-facing health and social care staff should be the first groups to receive Covid-19 vaccinations.
10.	The JCVI has since published advice about how the remaining adult population should be prioritised, based on age. It has also published advice about vaccinating children and young people and on a booster programme in autumn and winter 2021/22.
The Scottish Government set out its priorities in three vaccine deployment plans
11.	The Scottish Government has published three vaccine deployment plans since the start of the Covid-19 vaccination programme. These plans set out the high-level priorities of the programme, how it will be managed and summarise progress.
•	First plan – published January 2021. This set out the Scottish Government’s aim to vaccinate everyone in Scotland over the age of 18 and those aged 
16 and 17 years who are frontline health and social care workers, young carers or have underlying health conditions. These groups amount to 4.5 million people.
•	Second plan – published in March 2021. This provided a summary of progress to date, highlighting that the programme was progressing faster than planned and with high uptake. It set out plans for the next phase of the programme and outlined some of the measures being taken to ensure that the vaccine programme is inclusive. 
•	Third plan – published in July 2021. This provided a summary of progress and achievements since the start of the vaccination programme. It also outlined priorities for the next phase of the programme, including vaccinating eligible children and young people, and planning for a potential vaccine booster programme in autumn 2021.
The Scottish Government and NHS boards have worked closely to deliver the Covid-19 vaccination programme
12.	The Covid-19 vaccination programme is categorised into three tranches. More information on the priorities of Tranches Two and Three can be found on pages 15 and 16.
•	Tranche One consisted of vaccinating all adults in Scotland with two doses of a Covid-19 vaccine. 
•	Tranche Two consists of the autumn and winter 2021/22 flu vaccinations and Covid-19 booster programme.
•	Tranche Three focuses on the longer-term, business-as-usual approach to providing vaccinations in future across Scotland. 
13.	The Scottish Government set up a Flu Vaccination and Covid-19 Vaccination (FVCV) programme board to provide strategic direction and oversight of the planning and delivery of Tranche One of the Covid-19 vaccination programme. The board met fortnightly, and membership included senior officials from Scottish Government, NHS boards and other partners. 
14.	Several other groups reported to the FVCV programme board, including groups focused on clinical governance; programme delivery; planning; and communication and engagement. An Executive Group was also established for decisions that had to be taken between board meetings. All such decisions were recorded and reported at the next FVCV board meeting. 
15.	NHS National Services Scotland (NSS) has played a key role in the rollout of the Covid-19 vaccination programme in Scotland. It administers the allocation process for vaccines across Scotland and manages a contract for the storage and distribution of vaccines and sundries. It also developed and manages the National Vaccination Scheduling System (NVSS) and vaccination call centre.
Vaccines have been administered in a range of locations
16.	NHS boards have been delivering vaccines in a range of locations to reach as many people as possible. Vaccines have been administered in mass vaccination centres set up in conference centres and stadiums, and in local venues such as GP practices, town halls and community treatment centres. The Scottish Ambulance Service (SAS) has also set up mobile vaccination units to support the delivery of the vaccine programme. By the end of July 2021, 10,000 vaccines had been administered from SAS mobile vaccination units.
17.	As the economy reopened, the availability of some venues, such as stadiums and conference centres, decreased. The Scottish Government and NHS boards will need to consider how and where they deliver vaccines in the future. 
The vaccine programme has relied on temporary staffing, and a longer-term, sustainable workforce is needed
18.	The vaccine programme has so far been reliant on temporary staff and volunteers. By July 2021, more than 14,000 vaccinators had administered vaccines. Vaccinators consist of nurses, GPs, dentists, optometrists, pharmacists, allied health professionals, healthcare students and healthcare support workers (HCSWs). This diverse workforce has enabled the rollout of the vaccine programme to progress at pace, but it is an expensive model. Like other parts of the UK, NHS boards have also received support from the armed forces to increase vaccine workforce capacity when required. 
19.	As restrictions ease and NHS services recover, the availability of the temporary workforce will be reduced as staff return to their substantive posts. The Scottish Government has determined that a permanent, sustainable vaccine workforce will be needed in future. Work is currently taking place to establish the size of the workforce needed. This will depend on clinical advice about how vaccines should be delivered in future. The Scottish Government plans to recruit HCSW vaccinators as far as possible, working alongside registered nurses. 
New digital tools were developed at pace to support the vaccination programme
20.	To support the rollout of the Covid-19 vaccination programme, new digital tools were developed quickly. These digital developments have enhanced NHS Scotland’s ability to coordinate and manage the rapid rollout of the vaccines and required close collaboration and partnership working. NHS boards, such as NHS Education for Scotland, NHS NSS, Public Health Scotland (PHS) and NHS Greater Glasgow and Clyde, worked with the Scottish Government to develop new systems to support the deployment of the vaccines, including:
•	the National Vaccine Management Tool – a web-based application that enables frontline health and social care staff to view and record patient vaccination data at the point of care
•	the National Clinical Data Store – holds the Covid-19 vaccination records for everyone in Scotland, which can be securely shared with healthcare staff when required
•	the NVSS – used to allocate and reschedule appointments and will continue to be used for the next phase of the programme, including giving people the option to book appointments online
•	a self-registration portal – initially allowed unpaid carers to self-register for the vaccine before being rolled out to everyone aged under 30 years, and subsequently to all adults.
21.	NHS boards developed vaccine programme delivery plans in January and March 2021. In these plans, NHS boards identified risks related to the NVSS. There were concerns about the functionality of the tool before its launch, and challenges around the flexibility to schedule second doses. 
22.	Risks and issues relating to the NVSS were monitored regularly, and the NVSS was adapted to improve its functionality. Most NHS boards have used the NVSS and there are plans to continue using it in future stages of the vaccine programme. Some NHS boards have opted for local scheduling arrangements to better meet the needs of the local population. 
Vaccination costs for the 2021/22 financial year will depend on advice issued by the JCVI 
23.	Covid-19 vaccines are procured by the UK Government, so the costs in Scotland are associated with the management, distribution, and delivery of the Covid-19 vaccination programme. 
24.	In 2020/21, NHS Scotland spent £58.9 million on the Covid-19 vaccination programme. Territorial NHS boards account for the majority of this (£42.7 million), and NHS NSS spent £16.1 million. 
25.	In August 2021, NHS boards and HSCPs predicted that the Covid-19 vaccination programme for the 2021/22 financial year will cost £223.2 million. NHS boards account for the majority of this (£209.9 million). Of this, NHS NSS has predicted that its costs will amount to £61 million. 
26.	NHS boards have based their predicted costs on planning assumptions provided by the Scottish Government. The expenditure needed will depend on advice issued by the JCVI, so could differ substantially from current predicted costs. The Scottish Government has confirmed that vaccination costs will be fully funded for the 2021/22 financial year.
27.	As part of the initial Covid-19 funding allocations for 2021/22, the Scottish Government allocated £76.8 million for the extended flu and Covid-19 vaccination programme. Costs are being reviewed quarterly and further allocations will be made later in the year. 
Progress so far
Excellent progress has been made in rolling out the Covid-19 vaccination programme
28.	The Covid-19 vaccination programme is making excellent progress, with most of the adult population having received their first and second doses. By 21 September 2021, 7,979,142 doses of the Covid-19 vaccine had been administered in Scotland. Of all those aged 18 years and over, 91.7 per cent had received their first dose of a vaccine, and 85.7 per cent had received their second dose. This is considerably higher than the target of 80 per cent. 
29.	The Scottish Government aimed to offer first doses to everyone in JCVI priority groups 1-9 by early May 2021, and to all adults by the end of July 2021. This deadline was originally September 2021, but it was revised because of the good progress being made. First doses of the vaccine had been offered to all adults by 18 July 2021.
The vaccines have helped to reduce the number of people getting severely ill and dying from Covid-19
30.	The vaccines have helped to reduce the incidence of severe illness and death from Covid-19. The rate of cases and hospitalisations is significantly lower among vaccinated people, than for those who are unvaccinated. The most recent increase in Covid-19 cases during summer 2021 did not result in as significant an increase in hospitalisations and deaths as the previous waves of Covid-19 (Exhibit 2, page 11). As new variants of the virus continue to emerge however, there is a risk that the current Covid-19 vaccines will become less effective. 
The rate of people not attending their vaccination appointments has increased, but the proportion of vaccine wasted remains low
31.	The rate of people not attending their vaccination appointments (DNAs) has been higher in recent months. In February 2021, DNAs accounted for eight per cent of scheduled appointments. This increased to a high of 36 per cent in July 2021, before decreasing to 23 per cent in August (Exhibit 3). 
32.	It is important not to look at DNA rates in isolation. The uptake of Covid-19 vaccinations is very high, and there are factors that could account for the increasing rate of DNAs. For instance, all mainland NHS boards introduced drop-in clinics from early July 2021. This meant that people could be vaccinated when it is most convenient for them, instead of at their scheduled appointment time.
33.	The proportion of Covid-19 vaccine doses being wasted has remained consistently low throughout the vaccination programme, although it has increased slightly in recent months, with 2.3 per cent of vaccines wasted in August 2021. 
34.	The Scottish Government published guidance in March 2021 to help NHS boards to minimise the number of vaccine doses wasted. Some wastage is unavoidable and to be expected: for instance, depending on the equipment being used, or if there is a malfunction in the cold storage of the vaccines. In its planning assumptions, the Scottish Government anticipated that around five per cent of vaccines would be wasted. Between February and August 2021, the proportion of vaccines wasted was just 0.65 per cent (Exhibit 3).
Engagement with the vaccination programme is lower in some groups of the population
35.	Despite high uptake of Covid-19 vaccines overall, there is variation in uptake between different groups of the population. A smaller proportion of younger people, those living in the most deprived areas and people from some ethnic groups have been vaccinated (Exhibit 4). These trends are also evident in other parts of the UK. 
The Scottish Government and NHS boards are taking action to improve uptake of Covid-19 vaccinations
36.	The Scottish Government and NHS Scotland recognised that there would be challenges in vaccinating the entire adult population with a new vaccine, and that some groups would be more reluctant or less able to engage with the programme. 
37.	In November 2020, PHS led a health inequalities impact assessment (HIIA) for an extended flu and Covid-19 vaccination programme. This identified potential barriers to the uptake of flu and Covid-19 vaccines across different population groups, such as those from minority ethnic backgrounds and people living in deprived areas. The HIIA identified recommendations for the Scottish Government and NHS boards to consider when planning the vaccination programme. It was shared with the Scottish Government, NHS NSS and local NHS boards to inform planning and help them to develop their own equality impact assessments. PHS should publish the HIIA to share the findings 
more widely.
38.	Throughout the vaccine programme, the Scottish Government and NHS boards have worked with partners to increase uptake and reduce vaccine hesitancy through a variety of methods, such as:
•	improving data collection – to better understand trends by collecting data on uptake by characteristics such as ethnicity and deprivation 
•	working with organisations, such as Young Scot and the Minority Ethnic Health Inclusion Service, to tailor messaging for young people and those from ethnic minority backgrounds 
•	improving accessibility of information – for example, NHS Inform has published vaccine information in more than 30 different languages
•	a national inclusive steering group has been established to encourage vaccine uptake and reduce barriers to engagement with the programme. It has engaged with groups including African and Polish communities, where uptake has been low
•	outreach work – has targeted groups that may be less likely to come forward for vaccinations, such as Gypsy/Travellers, asylum seekers, those experiencing homelessness and seasonal migrant workers.
Next steps
The Scottish Government and NHS Scotland are preparing for future stages of the vaccination programme
39.	Tranche One of the vaccine programme has been effective in reducing the number of people getting severely ill and dying from Covid-19. It met its target to have offered both doses to the remaining adult population by mid-September 2021.
40.	The next stages of the vaccine programme bring further challenges. The Scottish Government has committed to continuing to follow advice from the JCVI in prioritising vaccine deployment beyond September 2021. In recent months, the JCVI has published a range of guidance on the next steps that the Scottish Government and NHS Scotland have needed to operationalise quickly, including:
•	30 June 2021 – interim advice on a potential Covid-19 booster programme starting in the autumn for vulnerable and older adults; final advice was issued in September 2021
•	19 July 2021 – advice that children aged 12-15 years at increased risk from Covid-19, and those aged 12-17 years living with someone who is immunosuppressed, should be offered the Pfizer-BioNTech vaccine
•	4 August 2021 – advice that all 16 and 17 year-olds should be offered a first dose of the Pfizer-BioNTech vaccine
•	1 September 2021 – advice that a third dose should be offered to people aged 12 and over who were severely immunosuppressed at the time of their first or second doses
•	14 September 2021 – advice that people in priority groups 1-9 should be offered a booster vaccine dose, no earlier than six months after having received their second dose of the vaccine.
41.	The Scottish Government has responded quickly to JCVI advice, with vaccines for eligible groups being offered within days of the advice being published. In many instances, the Scottish Government and NHS boards have had to plan for future stages of the vaccine programme with formal clinical advice from the JCVI yet to be confirmed.
42.	Final advice from the JCVI on the booster programme was issued in September following the results of clinical trials. This made planning particularly challenging, as it is the same month that the JCVI suggested in its interim guidance that a booster programme should begin.
43.	In advance of final JCVI advice, the Scottish Government started planning to provide booster vaccines from September 2021. It established a programme board for Tranche Two: the flu vaccine and Covid-19 booster programme. This board is intended to increase focus and the pace of planning and delivery of Covid-19 booster and flu vaccinations that is taking place over autumn and winter 2021/22. It has been meeting fortnightly since the end of June 2021.
44.	The Scottish Government developed a central planning scenario, informed by the JCVI’s interim advice and by discussions at the Tranche Two programme board. The Scottish Government has asked NHS boards to develop delivery plans for the flu vaccine and Covid-19 booster programme based on this planning scenario. There was a risk that changes would need to be made at short notice, once the JCVI issued its final advice. Some elements of the central planning scenario that were subject to that final advice included:
•	eligibility for booster vaccines and how boosters would be prioritised
•	whether flu vaccinations and Covid-19 booster jabs could be administered at the same time – this has a particular impact on the staff and infrastructure needed to deliver the vaccines
•	the dosage and type of vaccines that would be used for Covid-19 boosters, including whether the vaccine should be the same as that given for the first two doses, a different vaccine, or if either case could apply.
45.	The Scottish Government has also started planning for the longer-term, business-as-usual approach to providing vaccinations in future across Scotland: Tranche Three of the Covid-19 vaccination programme. It plans to establish a new National Vaccinations Partnership portfolio board to provide oversight and direction across all three tranches of the vaccination programme, but its primary focus will be on Tranche Three. This board will link with existing groups, such as the Scottish Immunisation Programme and the Vaccine Transformation Programme, to ensure that the strategies and directions of the groups are aligned.
Endnotes
	The Medicines and Healthcare Products Regulatory Agency is an executive agency sponsored by the UK Department of Health and Social Care. It regulates medicines, medical devices, and blood components for transfusion in the UK.
	The Joint Committee on Vaccination and Immunisation advises UK health departments on immunisation programmes. 
	The Barnett formula is used to allocate resources to Scotland, Wales and Northern Ireland when the UK Government spends money in areas that are devolved to the relevant administrations, such as health or local government. The funds received by devolved administrations are known as Barnett consequentials.
	Coronavirus (COVID-19): vaccine deployment plan,  Scottish Government, January 2021.
	Coronavirus (COVID-19): vaccine deployment plan,  Scottish Government, March 2021.
	Coronavirus (COVID-19): vaccine deployment plan,  Scottish Government, July 2021.
	10k vaccines delivered from SAS mobile vaccine clinics,  Scottish Ambulance Service, July 2021.
	Coronavirus (COVID-19): vaccine deployment plan, Scottish Government, July 2021.
	NHS Covid-19 funding increased,  Scottish Government, July 2021.
	Daily trend of total vaccinations in Scotland,  Public Health Scotland, September 2021.
	Coronavirus (COVID-19): vaccine deployment plan, Scottish Government, July 2021.
	Extended flu and COVID-19 vaccination health inequalities impact assessment (HIIA) Engagement and consultation report, Public Health Scotland, November 2020.
	NHS Inform is Scotland’s national health information service. It provides information to the public on health services, national health campaigns and other topics to help them make informed decisions about their health.
	Vaccination Strategy: inclusive programme board papers, June 2021.
 
Appendix
JCVI Priority Groups 1–9
•	1.	Residents in care homes for older adults and their carers
•	2.	All those 80 years of age and over and frontline health and social 
care workers
•	3.	All those 75 years of age and over
•	4.	All those 70 years of age and over and clinically extremely vulnerable individuals
•	5.	All those 65 years of age and over
•	6.	All individuals aged 16 years to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality, and 
unpaid carers
•	7.	All those 60 years of age and over
•	8.	All those 55 years of age and over
•	9.	All those 50 years of age and over