This article appears as part of the Inside the NHS newsletter.

An investigation by Public Health Scotland set out to explore the reason behind a "trend of declining baby and pre-school immunisation rates over the past decade", which comes against a backdrop of recent spikes in whooping cough and measles.

These "small, but accumulating declines" in uptake have prompted "cautious concern", said PHS.

Its newly-published report identified a number of obstacles and complications.

Fear

Most of NHS immunisation coordinators interviewed for the research mentioned "anti-vax sentiment", including "some very, very vociferous antivax families".

Conspiracy theories were spread on social media or by "local opinion leaders", including claims that the MMR vaccine causes autism or that aluminium in vaccines is bad for children's health.

The "increased spread of misinformation during the Covid-19 pandemic" had led to increased hesitancy and contributed to a "vaccine fatigue", and some parents were uneasy about exposing their child to multiple inoculations in one sitting.

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One interviewee said "four vaccines in one time is quite scary for parents... [some] choose to have two and then come back for the other two".

The report also suggested that some parents were missing appointment letters because of a "fear of opening letters that look official and could include bills".

Among the Polish community – the largest non-British population in Scotland – there was a tendency to want to "stick to their home country's vaccination schedule and decline certain vaccinations that are offered in Scotland".

System flaws

Appointment letters should arrive roughly two weeks prior to the vaccination date, but there have been "problems with timely delivery" such that "in some cases they only arrive the day before or even after the date of the scheduled appointment". The company responsible for posting the letters has been notified about these delays and the process is "under review".

The report also suggested that the way children are prioritised on the waiting list "is possibly ineffective". The Scottish Immunisation and Recall System (SIRS) sends invites out to the youngest child first, meaning that as youngsters miss appointments – for whatever reason – they are bumped down the queue when it comes to issuing new appointments.

The report states: "This not only means that the older the child, the further down a queue list they end up, but it also means that when catch-up clinics are scheduled, those children towards the end of the queue get scheduled at later times in the day.

“This can then turn into a vicious circle, as if a parent/carer can never bring their child for afternoon appointments, they move further down the queue list."

(Image: Derek McArthur)

Logistics

Responsibility for administering vaccinations in Scotland has transferred from GP surgeries to health boards.

In some areas, NHS immunisation coordinators noted that finding places to host vaccination sessions was problematic since "venues that were free during the Covid-19 pandemic are now either unavailable or the associated costs cannot be covered".

This was particularly difficult in more remote areas where there was an ambition to "get the vaccinations to those villages so that people don't have to travel" but no money available to hire spaces, such as church halls.

Staffing shortages and problems with staff retention in vaccine teams were also cited by "multiple" health boards.

Lessons from the pandemic?

Perhaps surprisingly, the national lockdown in 2020 was actually associated with a small bounce in childhood vaccination uptake.

One explanation put forward in the report is that some NHS regions altered their appointments system during that period so that instead of being invited by letter to "timed appointments" parents were given the chance to book the appointments themselves. This "allowed them to select a time more suitable for themselves".

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Four years on, 13 out of the 14 health boards in Scotland are back to operating childhood vaccinations on a timed appointment system.

Meanwhile, seasonal vaccination programmes – such as those for Covid and flu – tend to offer drop-in clinics alongside scheduled appointments.

The report recommends “increased scheduling flexibility” – enabling parents to choose a time and location that suits them – as one of the measures to boost uptake.