The contentious introduction of a vaccine mandate for staff in elderly care homes in England in 2021 was an attempt to protect some of the country’s most vulnerable people and ensure adequate and sustained care. However, a recent study in Management Science suggests that the intended effects were not achieved. In fact, it appears that there was no evidence of a reduction in resident deaths but a “reduction in net staffing”. Through an analysis of local authority weekly data from the Department of Health and Social Care, the authors investigate the significance of the vaccine mandate for vaccine take-up, staffing levels, and mortality.  

What is a mandate and why was it imposed? 

A mandate is an official order or requirement to do something, and in the case of the COVID-19 pandemic it was deployed by many governing bodies to enforce protective measures. An article by the authors of the study in The Conversation suggests that a lot of attention to mandates focuses on ethical issues. There is a tension between anticipated benefits of a vaccine mandate, such as a reduction in deaths, and the argument that “vaccination as a condition of employment can never be justified” due to “the right to refuse healthcare” and “objections to the use of coercion”.  

Nonetheless, in June 2021 the policy requiring COVID-19 vaccination for care home staff was announced, with a deadline for two vaccinations established for November 2021. This met union opposition, with Unite calling for “encouragement, not compulsion”, strongly opposing “forcing” workers to take a vaccine or “risk sacrificing their job”.  

“Compulsion is a very bad way to achieve a high-level response, will lead to increased resistance, a worsening staffing crisis, and is embroiled with issues such as equalities, human rights, privacy, and ethical breaches.”

The mandate allowed “limited” medical exemptions but did not permit exemptions due to objection or previous COVID-19 infection. So, what bearing did this mandate have on the strained staffing situation, and did it lead to better survival outcomes for a vulnerable population? 

The study 

The researchers compared take-up and staffing in elderly care homes relative to other settings that were unaffected by the mandate as well as the elderly care setting in Wales where the mandate did not apply. They also compared COVID-19-related mortality in English elderly care home residents with that of domestic homes in England and care homes in Wales.  

The results paint a negative picture of the environment created by the mandate, suggesting that although it “substantially decreased the proportion of care home workers who remained unvaccinated”, this came at the “cost of a reduction in staffing levels of between 3% and 4%”. This is equivalent to between 14,000 and 18,000 staff. This was “most strongly” observed in areas of “low unemployment”.  

“Our results do not provide evidence that the vaccine mandate was successful in its primary aim of reducing care home deaths.”  

To ensure that the changes were attributable to the mandate, they were compared to changes in the groups where the mandate didn’t apply. They found that by the deadline of November 2021 there were between 28,000 and 41,000 fewer unvaccinated staff working in English elderly care homes than had the mandate not been established.  

“Notably, a significant proportion of this drop in numbers came at the expense of unvaccinated carers leaving the sector without being replaced.”  
What about deaths? 

The study also considered the potential effects of the mandate on COVID-19 mortality among residents of care homes in England. Compared to English domestic homes and Welsh care homes, the results failed to provide evidence of a reduction in deaths. However, this is perhaps less unexpected than we might think. Some of the reasons for this include the effectiveness of COVID-19 vaccines against infection and transmission being “more limited than was originally hoped”. Furthermore, vaccination “may induce behavioural effects that narrow the difference in risk between vaccinated and unvaccinated groups”.  

Although there was no evidence of an effect on deaths, the authors emphasise that this “isn’t quite the same as proving there’s no effect”. However, the effect was too small, whether positive or negative, to be identified as statistically significant in the data.  

Was the mandate a success or a failure? 

The authors confirm that one of the initial concerns about the policy, that it would lead to an exodus of carers from the sector, was realised.  

“Our evidence confirms the mandate did have a significant effect in this regard.”  

They encourage “caution” from policymakers when considering similar mandates in future crises. Do you believe the mandate was a success or failure? Were you affected by the mandate, and do you think it would be a good idea to implement something similar in a future pandemic threat? 

To request access to the study please click here or read the article in The Conversation here. Don’t forget to subscribe for more on vaccine strategy and policy every week.