OK, so, this has been causing a bit of a stir lately and inspired me to seek out some clarity in my own thinking (which has become rather muddied of late) from multiple sources.

For a document that clearly seems to indicate that ‘HCAs can’t perform informed consent’, I have come across SO MANY DIFFERENT INTERPRETATIONS AND OPINIONS. So many thoughts…. I’ve talked to so many people, some with very strong views on all sides. I’ve disagreed with colleagues; they have disagreed with me in return. It’s been heated at times.

I have questioned many aspects of immunisation practice and bigger picture stuff (still am) and dug deep within myself as well. I’ve questioned my teaching given that I feel like I’m even struggling with grasping the fundamentals of care, like consent, at the minute. I’ve no doubt (looking at the forums) that others in practice have also questioned themselves and their own practice and had a little panic around ‘are we doing it right’?

I can’t say I am not disappointed by this UKHSA statement around consent - knowing that the realities of general practice (in particular) means that this will inevitably lead to more barriers for certain vaccinators. Therefore, here we go again with continued uptake battles. And this time, painfully spurred on by the very guidance that seeks to improve our vaccination standards. Some clinics rely heavily on competent, trained, and experienced HCAs having at least a part in the consent process, and that final stage in particular – where the checking of consent AT THE TIME of vaccination - is the sticking point for me here. I feel like my initial disappointment on reading that line has made me go; "say it isn’t so UKHSA!”, and try to find any way that it can’t actually be true. Because I know in my heart that this statement could mean the operationally-unfeasible demise of many HCAs being involved in vaccinations that require a PSD and not under national protocol, such as shingles and pneumococcal. To some general practice staff that I've spoken to, that may come as a relief, to both HCA's and registrants. To others it is DEVASTATING!

I’ve had various discussions on courses, but I have remained quiet on the nurse forums about this, despite the urge to contribute to discussions and help colleagues that are reaching out for answers of their own. I haven’t felt like I’ve had a well enough formed opinion yet. Maybe, on reflection, perhaps I have even been sulking a bit? I often have to ruminate a while before concluding my internal deliberations. So, when in the classroom I’ve been just doing what teachers are supposed to do, which is highlight guidance, stimulate thought on processes in the workplace and how well they comply with guidance, and encourage the seeking of clarity from the channels that can offer it. These would be ICB’s, PCNs, and the UKHSA themselves. I’m not in a position to provide authoritative interpretation of these guidelines, nor can I advise (without getting in a bit of trouble) on how any organisation should modify its current clinical practice or staffing models. I have however, been going to town on information-giving in general practice in an effort to encourage the enactment of 'consent' as part of a process, not a one-off event to be managed by one HCA on their own. This should never be the case to shift the entire responsibility of informed consent to a HCA. THAT, I can agree on.

So anyway, I’m listing here everything I have looked at (from informal conversations to the law to governing bodies…) to try to make sense of this apparent restriction to the practice of the HCA. I hope it helps someone out there to also reflect on their own position – which may of course be very different to mine. And that’s ok. I’m pretty used to disagreements after all this! I just want YOU to have everything I have had to help get my head around this. And if you are one of the people I have debated with and sought opinions from (you know who you are) a special THANKYOU to you for your honest and thought-provoking answers to my incessant questions.

Governance systems: What should THEY look like?

Whilst the NMS (which is not the law, but a very important guideline) describes HCA's 'not being able to consent', local governance may turn out to be less prescriptive (no pun intended) around ‘consent’ when it comes to medicine administration by non registrants. Local guidelines and SOPS are the key here to ensure everyone knows what’s what, who’s who, and where everyone’s boundaries lay around the consent process.

What might a practice need to consider on the back of the NMS position on consent?

If I were reflecting on my own clinic systems around vaccination consent and what it really means to obtain informed consent, I would ask myself the following:

• Is there a medicines management policy in place outlining roles and responsibilities clearly?

• Is everything that's expected of a HCA written down somewhere when it comes to them administering medications given under PSD?

• Are HCAS left to make decisions alone or is it a wider process when it comes to vaccine consent?

• Do prescribers have any conversations with patients about vaccines before writing a PSD? Or at any point in the process after writing one? Is this documented anywhere?

• How do we ensure that our systems ingrain consent into everything; from sending out information to bringing up vaccines opportunistically and documenting discussions that may help indicate an appreciation of wanting to accept a vaccine so there’s an audit trail of informed discussions with reg’s before the vaccinee even reaches a HCA.

• When does a HCA defer to a registrant in a consenting situation? And how do we ensure they know what constitutes a ‘referral’ situation?

Here’s what SPS says:

“Whilst any suitably trained and competent person may follow a PSD for administration, some organisations may extend or limit those who are authorised to administer medicines under a PSD within their local medicines policies and governance arrangements. The employing organisation has a duty of care to both the individual under their care and to the professionals they employ. The employer is responsible for ensuring that the healthcare professionals it employs are properly trained and undertake only those responsibilities specified in agreed job descriptions. If expecting non-regulated staff e.g. healthcare assistants to administer medicines, those delegating the duty must ensure that the non-regulated staff are competent.

PSDs may need to be supported by a locally approved procedure or guideline to support safe supply and/or administration of the medicine by an appropriately trained and competent healthcare professional. Prescribers and any person administering or supplying medicines must ensure that they adhere to local clinical governance policies and procedures and associated arrangements."

They also state here: "Organisations have a legal duty of care and are responsible for ensuring a Medicines Policy is in place and that the staff they employ are properly trained and competent to undertake only those responsibilities specified in agreed job descriptions.

Prescribers & Delegators:

What is THEIR position?

Under a PSD, the prescriber takes responsibility for the clinical decision and remains accountable, but they CAN delegate the administration. More often than not it's the GP who does the prescribing, but there are plenty of nurse prescribers out there too. And a delegator is not necessarily a precriber. HCA's come under the nursing support workforce so thier role is delegated (usually) by the nurse seniors.

The Registered Healthcare Professional who delegates the role of administration (even if NOT the prescriber) also therefore remains responsible for ensuring the HCAs competence, and ensuring information is provided sufficiently that when patients are consenting to the procedure of being immunised, that the patient has had all the information necessary to make an informed decision AND that the HCA would be able to identify if informed consent has actually been gained (or not) and raise issues as necessary. A very responsible position to be in eh? And from what I have heard along the way, prescribing primary care nurses do not seem to be indemnified in the same way that pharmacists or GPs are so there may be nuances around implications for different prescribers too.

Organisations need to show that delegation, consent and competence are built into their systems so that the whole task of consenting is not put on the HCA entirely and that the HCA understands the boundaries of their role. I would argue that this is nothing new and should have already been the case in practice before the revision of the NMS. Some prescribers I have spoken to have not been confident that their HCA’s would indeed have the bigger picture knowledge that nurse training provides to be able to stick to these boundaries OR that they do not have time to adequately supervise the situation. So, in good conscience, they simply have not been delegating this task to HCAs. Which is fair enough.

I take a perhaps utopian and (unrealistically?) positive view here in that this is exactly why we need to ensure that foundation training (and consequent supervision and support within the team) is of an excellent standard. I’ve been asked the same intelligent questions in courses by both nurses and HCAs. I hence feel like both roles kind of start at a similar baseline of knowledge when we are taking specifically about vaccines. Yes there is a wider context it all sits in, granted, a nurse or doctor will know more bigger picture stuff. But if the training is of a high standard then both roles come off an immunisation course well-informed.

FURTHERMORE, and I know this might not be a popular view, I’d even go as far as to say that I strongly suspect that some HCAs come off the immunisaion courses knowing MORE about the immunisation in question than some prescribers who are prescribing the vaccine…

Am I perhaps being a bit bold there? Why do I say this? I often highlight to HCAs on the courses how lucky they are to only be learning in detail about a handful of vaccines when the nurses have to go though nearly 20 of them in the same short time period. I can tell you with confidence which type of professional generally comes off a course ‘more informed about shingles’ immediately after, and that would definitely be the HCA’s who get the luxury of over an hour specifically on that disease alone, compared to the measly (again, no pun intended) ten minutes or so that a nurse gets amidst a sea of other vaccines… And after the course, there is so much more for nurses to learn and digest.

Nurse and Pharmacist Independent Prescribers must also incidentally ensure that patients are aware that they are being 'treated' by a non-medical practitioner and of the scope and limits of their prescribing, AND all staff must make it clear to their patients what their job role is (as we know, patients often think ‘all nurses are women and all doctors are men’). How do we communicate these things? This is not easy for a non-medical prescriber to ensure, especially from a distance!

I’ve spoken to some very senior nurse prescribers that I greatly respect and value the opinion of. For transparency my disclaimers are;

• 1. I am not a prescriber myself.

• And 2; my immunisation setting experience comes from private practice.

Yes, I am an imposter in the field of general practice and I always state the limits of my experience there. However, reassuringly, I teach to the minimum standards therefore the principles are all the same in any context when getting someone to the standards required for good immmunisatinon practice. But it’s important that I listen to those in this particular setting of GP land (and also in my defense, I meet, on average, 200 GP staff members a WEEK where I learn a lot from them along the way).

It is clear we are not in an ideal world with infinite staff and resources, there are constant pressures to increase uptake in general practice and to stretch staff and other resources thinly. GP surgeries provide probably the lions share of routine immunisations, so it's no surprise that immunisation courses are largely populated by GP staff. But even so, a small village practice with one GP, one nurse and one HCA may well have completely different issues to those in a large inner city practice with 3 GPs, 6 nurses, 3 locums and 4 HCAs. Hence, there are inevitably mixed views on the reality of the situation and this has led to the wider question of ‘should HCAs even be vaccinating in the first place?

Some nurse prescribers/delegators (and I greatly appreciated the honesty) explained to me how given the realities of busy practice they do not feel comfortable prescribing for HCA administration as it is, when they may not know (or have time to know) for definite if each HCA they work with is fully competent. Some delegators also expressed concern for HCAs themselves and felt a need to protect them from ever-widening roles. Some said they welcome and embrace HCAs assisting them with vaccinating and feel very confident that their staff are trained to high enough standards and they know and trust them well. I thus think individual situations, set-ups, and working relationships are important considerations here. And I think attitudes are formed via experiences in practice and the context someone is in. Some have had great experiences collaborating in their teams and others, sadly, have not. This all goes towards shaping a viewpoint on this particular issue which will inevitably be a big fork in the road between my opinion and someone else’s. I guess you know what feels right for your practice and what works well for one, may completely flop for another.

So my suggestions for reflection if you are a prescriber (or delegator):

• What do YOU feel comfortable with here when it comes to delegating to HCA involvement with consenting for vaccinations?

• How do you ensure and monitor competence in your vaccinators?

• Are YOU satisfied that you are delegating this task to a competent individual that would come to you when any doubts are raised?

• Is there even a NEED for HCAs to be vaccinating in your place of work? Or is it a relatively straightforward switch to not having them doing so?

Immunisation Teachers:

Where do they come in?

As a teacher myself, I feel my role is to teach principles and THINKING and how to approach problems encountered. So that when things like this come up, a person is trained to be able to intelligently deal with it and go to the right people in practice, or the right guidance for advice, or think through a problem in an evidence-based and logical way. On immunisation courses, although there may be less quantity of vaccines covered, HCAs are taught the same broader things as registrants so they are aware of why we give the vaccines we give, side effects, what consent means, and so on. They have to know these things if they are to be aware of when to stop and defer to a registrant.

The guidance is not meant to remove professional judgement and this is why it’s impossible to give a blanket bit of advice on this that would suit all areas of practice. Practices have to look at what is best and safest for THEM and their patients using the resources and staff they have. The same process won’t work well everywhere so as trainers we should be willing to have discussions and invite the thoughts of others and share experiences and ideas. But we cannot prescribe an approach. It’s much easier to say when things are being absolutely done incorrectly or unsafely than it is to corroborate with well-designed practices that are happening in a context that is unfamiliar to the tutor.

Some of my fellow trainers (I speak to a LOT of them too) are reluctant to touch this topic in too much detail, leaving it to the practice to interpret the guidance in the way that works for them. Others are avidly expressing their views and giving suggestions for practice. Depending on whether you are independent (therefore your views are only reflecting that of your own) OR working for an organisation (in which case you have to be careful because you are inadvertently representing a standpoint of a whole company) OR teaching within your own organisation and you're in senior management there, this may again have a bearing on how much detail is discussed.

I read a scathing Facebook comment recently that stung a bit (teachers regularly get the blame for stuff), and it was a nurse who was clearly annoyed that her training (not sure who it was with) hadn't covered this mammoth topic. I appreciate that sometimes people just want definite answers to things and it gets annoying when they are not forthcoming. But I hope this reflection helps to explain why it is so hard to have a 'position' other than what the guidance says when it comes to stuff like this. I can pretty much guarantee that every immunisation course will be mentioning that the guidance has been updated in June - but the onus is on the delegates to scour it and work out if their service meets the guidelines out there in my humble opinion. Classes can be large - and not everyone on it will even need to visit this issue if they don't use HCA's for vaccination. Let me also take this opportunity to say we, as trainers, rely on interactive delegates asking questions that are important to them to shape a course into one that meets the needs of everyone on it. If you need to talk about this some more, raise it.

Also, we don't write the actual training guidance. And sometimes WE struggle to understand what government intentions are too.

Don't shoot the messenger.

HCAs:

Where does this leave them?

Registrant or not, a person who administers a medicine is accountable (to the law) for their own practice and must be trained and competent to undertake such tasks. They must act according to their level of competence and in accordance with the directions of the prescriber/delegator. Some of the registrants I spoke to over this issue were questioning how seriously this is taken by non-registrants. Especially when a prescriber (and the accountable nurse, if not the prescriber) remains professionally accountable for everything and a surgery carries vicarious liability.

How do HCAs therefore ensure their own competency then? Can they be expected to know if they are truly competent without a wider context of medical training that nurses and doctors go through? This is why we have the minimum standards and associated competencies for training perhaps… ?

I started off my career as a HCA and for many years, I was probably doing things that I didn't realise were even things I shouldn't have been doing. Plenty of medication administrations in people's homes with not a registrant (or even a phone number for one) in sight. Dressings, insulin injections, you name it, I probably did it. But I can say with my hand on my heart that I did all those things with conscientiousness and care. I look back and cringe, yes. And this is perhaps what our registrant training teaches us - the much bigger picture about where our roles sit.

I have noticed however, that I've had MORE questions and concerns raised about this topic of consent from HCAs than I have from nurses. WAY MORE in fact. I'll leave that one there for interpretation (sorry, another one to figure out).

So, a couple of things to reflect on here:

• A very common thing I hear is that PSD's can be very casually prescribed (sometimes with NO individualised assessment at all, and simply 'batched' due to eligibility criteria alone, with no consideration for contraindications for example) then the HCA is expected to take the reigns from there. Patients turn up not knowing what they are even coming for. Is this good practice? NO. Where does consent come in here? Is the HCA FULLY responsible? Have a think about your entire process from start to finish. How does it work locally and is 'getting the public vaccinated' truly a TEAM approach? I feel like some practices I have spoken to actually really need this jolt to help them revisit what they are doing.

• I would also urge all staff to consider how much responsibility each person takes on and whether or not the HCAs are being pushed out of their boundaries in other ways locally, not just with regards to consent, but around assessment too (and yes, I have heard HCA's sometimes get involved in a bit of illegal prescribing by adding the PSD themselves from time to time!). Where is the oversight in your context?

CONSENT:

What is even meant by'consent'?

A process? A team effort? A journey that begins before the PSD is even written? Consent contains many steps, such as a patient choosing to book an appointment, receiving and digesting information, turning up, offering out their arm… all of these things imply consent is taking place.

• Does every practice truly consider thoughtfully how information is provided and how inequities are addressed (such as language, culture and digital inequalities) regardless of who ends up giving the vaccine?

• Does ANYONE who is giving a medicine under PSD truly check exactly what information the patient has been provided with and whether they understand it? How much of this checking goes on in the middle of a busy flu season with 2 mins per patient where they barely even sit down?

Therefore, what implications does this have for registrants as well as non-registrants? What ‘better job’ are nurses doing to HCAs that means they can gain informed consent in 15 seconds and a HCA cannot?

Consent cannot be purely a one-off event at the time of the administration. Yes, it HAS to be given at the point of administration. But the consenting process starts way before that.

Coercion would be if we forced people to have their vaccines, or were unaware of the MCA and vaccinated someone who did not have capacity, or didn’t check they knew what they were actually agreeing to (or not). How many of us actually thoroughly check this? How deep does it need to go? How MUCH information is needed and how do we satisfy ourselves that this is truly consent? In many cases the simple facts a patient would have access to in 15 seconds if they were not sent information in advance, might be something like ‘flu is bad, vaccines are safe, you are eligible’.

Perhaps this is a reminder that we ALL need to revisit how much informed consent we gain when using PSDs, PGDs, protocols or otherwise…?

THE GREEN BOOK:

What is in there about who can 'consent'?

I couldn't see anything in there about WHO can consent for a vaccine, the Green Book is more concerned with doing it CORRECTLY and it is mostly aimed at the principles behind consent. (UPDATE: just after I wrote this piece the consent chapter was UPDATED in October 2025 and now it does offer more clarity)

Bits that are relevant to the discussion here (make of it what you will) are that it does point out that:

"Case law on consent develops and changes over time. Those involved in seeking consent for immunisation should keep up to date with latest developments, legal rulings and their employing organisations’ policies and procedures on consent."

And also:

"Consent is a process rather than a one-off event. Consent may be withdrawn at any time and consent obtained for 1 immunisation does not necessarily remain in place for all future doses of a course of immunisation. Where consent has been obtained for a full course, however, it is not necessary to seek consent again for each subsequent vaccine unless new information has come to light. It is good practice to check that the individual is content to proceed at each stage."

"People must be listened to, given the information they require to make decisions about immunisation and given sufficient time and support to understand that information. Information should be provided in a way the individual can understand, ideally before the immunisation appointment"

In the edition I was reading prior to the update they used the term 'healthcare workers' mostly, and did not specify a preference for which profession takes consent. And they also aligned (still do) with all the other perspectives and specify that health professionals should ensure they are working within their competence and scope of practice (whatever that ultimately may mean). But NOW it says:

"Information should include details of the process, the benefits of immunisation, and the risks, including known side effects and what to do if they occur. A healthcare professional with the necessary knowledge and understanding of the vaccination being offered should provide this information, so that they can answer any questions about it to help the person consent to it. Where feasible, healthcare professionals seeking consent should find out what matters to individuals so that they can share relevant information about the benefits and risks of immunisation, including the risks of not proceeding with immunisation. Whilst it is outside the scope of healthcare support workers to seek informed consent to treatment with a vaccine, they may seek consent to administer a vaccine for which informed consent has been gained by a registered healthcare professional." P2.

Again this further reinforces the view of consent being an information-giving process and not a one off event to be conducted by HCAs alone.

NMC:

What is their perspective on safe medicine delegation and consent in regards to HCAs?

Again, the revised NMS seems to stand alone in the perspective of 'HCAs cannot gain informed consent' because the NMC do not specifically sanction this either. Under the NMC Code (2018) and Delegation and Accountability: Supplementary Information to the Code, a registered nurse, midwife, or nursing associate may delegate a task — even one involving the administration of medicines — to a non-registered colleague (such as a healthcare assistant), provided that all the following conditions are met:

1. Competence and scope: The task must be within the non-registrant’s scope of competence. The registered professional must be satisfied that the individual has the appropriate training, skills, and experience to perform it safely. (NMC Code section 11.1 – “Only delegate tasks and duties that are within the other person’s scope of competence.”)

2. Clarity of instructions and boundaries: The non-registrant must fully understand the instructions and be clear about their limits of responsibility — including when and how to escalate concerns or refer back to the registered professional. (NMC supplementary guidance, Delegation and Accountability – “Make sure that the person understands the instructions and knows when to seek help.”)

3. Accountability: The registered professional remains accountable for the decision to delegate, for ensuring appropriate supervision, and for the standard of care delivered. Accountability cannot be transferred — only the task can. (NMC, 2018 – “You are accountable for your decisions to delegate tasks and duties to others.”)

4. Supervision and oversight: There must be appropriate supervision, support, and monitoring in place. The registered nurse must be able to confirm that the outcome of the delegated task meets the required standard and that patient safety is maintained. (NMC supplementary guidance – “Confirm that the outcome of any task delegated meets the required standard.”)

Can you use those points to help reflect on where delegating consent might apply to your own practice? The NMC stance DOESN'T necessarily rule out being able to delegate consent in appropriate circumstances as far as I can see...

Application to vaccination under a PSD

When a vaccine is administered under a Patient Specific Direction (PSD):

• The prescriber is accountable for assessing suitability and authorising administration.

• BUT the HCA is part of the nursing team therefore the registered nurse (regardless of being a prescriber or not) is still accountable for the delegation.

• The registered nurse may delegate the administration (and associated consent check) to a trained and competent HCA.

The nurse must ensure:

• The HCA is trained, competent, and up-to-date in vaccine knowledge and technique.

• The HCA understands boundaries — e.g., when to stop, escalate, or refer.

• There is a clear Standard Operating Procedure (SOP) describing governance, documentation, and supervision.

• The nurse or prescriber retains accountability for the overall safety and outcome of that episode of care.

The Law:

What does it say?

Nothing in the law has changed regarding HCA's being able to consent, as far as I can see, that could have led to this being included in the new NMS.

Simply: As far as the law is concerned, HCA’s can still physically vaccinate. This is the purpose of PSD’s and protocols (when used for HCA’s) as a valid legal mechanism for administration. HCAs cannot legally work under PGD and this has always been the case. The law says:

• The prescriber is responsible for assessment of the individual and the decision to legally authorise the supply/administration of the medicine(s) in question.

• The prescriber has a duty of care and is professionally and legally accountable for the care they provide including the delegation of any administration of medicines they prescribe.

• The prescriber must be satisfied that the person to whom the administration is delegated has the qualifications, experience, knowledge and skills to provide the care or treatment involved.

I have trawled the SPS website, and noted that nothing on SPS says that legally part of a PSD process involves the prescriber having to do the consenting part. Only initial and individualised assessment is stressed (see direct quotes below). Please correct me if I missed something there.

They say “Whilst not defined in legislation a Patient Specific Direction (PSD) is the traditional written instruction, signed by a prescriber for medicines to be supplied and/or administered to a named individual after the prescriber has assessed that individual on a one-to-one basis. In practice a PSD is commonly referred to as a prescription by those who write them or use them as the legal basis to administer a medication because this indicates that it is written by a prescriber. Following a clinical assessment, a written and authorised instruction may be made by a prescriber to administer a medicine to that individual. In a GP practice this may be written in an individual clinical record; in an acute inpatient setting, this might be an instruction written on an individual’s medicine chart. Careful consideration needs to be given to how the instruction is incorporated in the clinical record to ensure that the medicine is given safely and in a timely manner."

When it comes to clinic lists: The prescriber must have adequate knowledge of each individual’s health and be satisfied that the medicine to be administered serves the individual needs of each person on that list. An example would be a list of individuals to receive a seasonal influenza vaccine during a pre-booked vaccination clinic.

There should, wherever possible, be separation of prescribing and supply/administration roles. If this is not practical, undertaking a local risk assessment should be considered. Where clinical circumstances make it necessary and in the interests of an individual, the same health care professional can be responsible for the prescribing, dispensing and/or supply/administration of medicines.”

The RCN:

What do they say?

Awaiting thoughts and position statement – this will be a useful piece when it comes. However, worth noting that they have been previously very supportive of HCA’s safely getting involved with vaccinating under PSD for diseases such as flu, shingles and pneumococcal, and even nasal flu to children.

AND they have a tonne of useful stuff about accountability and delegation here if you want to check it out.

History and trends:

What direction is this going in?

Final thoughts.

Like the big bang, roles have expanded rather than narrowed over the years. Doctors didn’t like the idea of nurses prescribing 20 years ago, and look at it now! With blood-taking, nurses didn’t traditionally do it, then they did. Then HCAs started doing it, and now admin are doing it! We need to do what's best for patients with the resources we have and from what I can see, our roles are ALL expanding, all the time. And yes, there comes a point where a HCA might hit a ceiling, and then need to consider further qualifications to advance further (which is the path I took myself).

But is 'consent for vaccination' that ceiling? I personally don't think so.

My question is: Who is more ‘unsafe’ if trained and supported to the same standards? One prescribing nurse I talked to (who worked throughout the widening of prescribing laws) anecdotally pointed out to me that one reason she noticed that doctors were concerned about nurses becoming prescribers was down to all the errors they themselves were making! Hence this also in part led to the creation of the NMS eventually. This is why perhaps the biggest takeaway I have gained from exploring this topic is to consider - are we really doing this to the highest standards and how can we use the guidance to assess the overall quality and pathways within our immunisation services? Are we perhaps getting too hung up on the details of 'who can do what?'.

And what does all this mean? Perhaps importantly WHY is the revised guidance worded the way it is? What's the bigger picture here?

• Could all this be pointing us towards a model like Scotland where vaccination hubs have been set up?

• Could we see more use of the national protocols as a legal mechanism, especially where HCAs are concerned? What about protocols for vaccines other than flu and COVID-19?

• If HCAs stop getting involved what impact will this have on vaccine discussions in general? HCAs being trained to talk about vaccines (whether giving or not) is very useful. I would go as far as to say anyone can be talking about vaccines, perhaps admin staff, front of house, should also be trained more on immunisation discussions. It's not some secret club that only health care professionals are allowed to know about. But if they are not getting as involved due to the consent issue, then inevitably less HCA training will happen. Opportunistic discussions may lesson, or misunderstandings and hesitancy may increase if HCA’s are exposed only to the same sort of (often awful) things the public are?

• What does this mean for other injectable medicines like B12 as well? (the Green Book and the NMS are both frequently cited as 'good practice' guidance for non-vaccines). Delegators there will have had long discussions with patients about the reason for those injections and consent will have been gained at that point. But, consent has to be gained EACH time and at the point of administration if this applies here too. Does this mean the HCA has to go back each time to the prescribers for them to officially gain consent on the day or can the HCA be trained (as they are currently) to question when they do not believe a patient has indeed been informed enough to provide consent? OR is there a difference between gaining informed consent and checking informed consent has been given and remains in place as the Green Book suggests?

• The realities of General Practice means that a model where HCA’s cannot consent full stop to the procedure, even with a PSD, renders them (sadly, in my humble opinion) not operationally viable in a lot of PSD-related cases because prescribers haven't the time to turn up and discuss consent with every patient at the time and if they did have the time they would just be giving it themselves (hence why they are delegating the administration in the first place). This, in my opinion from what I have seen, could be be a significant blow to some areas of practice that have been maintaining good uptake through the use of responsible, competent and trained HCA’s working and consenting under PSD. National protocols can overcome this of course, however, we only have those for flu and COVID-19 so far. Not for the other important vaccines that are given in our national programmes, such as shingles and pneumococcal.

• To end more positively, I ultimately think these revised guidelines provide us all with an opportunity to reflect on our practice around consent and what it truly means to us and our patients.

NHS vaccination strategy

This arrived with us a couple of years ago and outlines some goals for vaccination. It focuses on improving equity and access to vaccinations, with a key goal of increasing immunisation coverage by 2030. Whilst it doesn't specifically comment on who should do the consent, It is very supportive of all staff getting involved with vaccines and integrating vaccine education into training from the start, widening the roles of who can vaccinate and talk about vaccines from admin staff to Doctors. For example, it says:

• “Help make vaccination the business of everyone working in patient-facing roles through training and awareness campaigns and widening the roles that can vaccinate to increase the number of vaccinators.” (proposal 3.3.8)

• “Develop a vaccination workforce with a skill mix that makes best use of trained, unregistered staff where clinically appropriate and subject to the appropriate legislation, and focuses registered staff on activities where they can bring most benefits including delivering other health and wellbeing interventions alongside vaccination” (proposal 4.3.2- 4.3.4)

• “Explore options to revise regulations that may widen opportunities for experienced, non-prescribing healthcare professionals to vaccinate by allowing delegation of vaccination to unregistered staff.” (proposal 4.3.5)

The middle bullet point is a little contradictory given that the new NMS (p7) states "they [HCAs] may be better employed in roles other than vaccine administration which will then maximise the capacity of RHCPs to undertake the more complex tasks".