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Mandatory COVID vaccination as a condition of employment has been a commonly used – though controversial – policy around the world during the pandemic.
Much of the debate on vaccine mandates has rightly focused on ethical issues. For some people, considerations such as the right to refuse healthcare and objections to the use of coercion mean vaccination as a condition of employment can never be justified, irrespective of how effective the policy might be.
Others argue that ethical objections need to be weighed against benefits such as potential reductions in deaths among the vulnerable. On this basis, vaccine mandates might be justified in some circumstances, even if such a policy requires substantial evidence that expected public health benefits will exceed costs.
The issues are particularly sensitive in the case of elderly care homes given the high vulnerability of residents to severe COVID. At the same time, if a mandate results in care workers being sacked or choosing to leave their job, it may add to staffing difficulties in an already stretched sector.
In our new study, we sought to estimate the effects of the 2021 COVID vaccine mandate for staff in elderly care homes in England. We found that the mandate was successful in reducing the percentage of unvaccinated workers, but this came at the cost of a reduction in net staffing in the sector. We also didn’t find any evidence that the mandate reduced COVID deaths among residents.
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The policy making COVID vaccination compulsory for care home staff was announced in June 2021. Despite trade union opposition, care workers were required by law to have had two vaccinations by November 11.
Exemptions from the mandate were provided for a limited number of medical reasons but not for conscientious objection to vaccination or for immunity from a previous COVID infection.
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Staffing
We used weekly data at the local authority level on the percentage of workers in elderly care homes who were unvaccinated, total numbers of care home staff and COVID-related deaths among residents. This allowed us to track the evolving effect of the mandate from the policy announcement to the final deadline in November.
Throughout this period, but especially at the final deadline, we observed falls both in the percentage of workers in elderly care homes who were unvaccinated and in total staffing numbers. The percentage of English care workers who were unvaccinated was about 16% before the policy announcement, dropping to just 4% after the final implementation (most of this 4% were likely to have claimed medical exemptions).
To tease out whether these changes can truly be attributed to the mandate, we assessed them alongside changes in two comparison groups where the mandate didn’t apply – workers in other care home sectors in England and workers in elderly care homes in Wales.
We found that by 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 in place.
Notably, a significant proportion of this drop in numbers came at the expense of unvaccinated carers leaving the sector without being replaced. Our estimates suggest the mandate caused a net reduction in staffing of between 14,000 and 18,000 employees, around 4% of the total workforce. The number of staff in elderly care homes when the mandate was announced was roughly 470,000.
Given that some unvaccinated staff will have been replaced by vaccinated staff, the total number of care workers who left their jobs because of the mandate was almost certainly much larger. We also observed a big increase in reliance on agency staff (rather than directly employed workers) over the same period.
COVID deaths
To understand the mandate’s potential effects on COVID mortality among care home residents, we used deaths in domestic homes in England and in Welsh care homes as comparisons. We were unable to find any evidence that the mandate reduced COVID deaths among elderly residents.
Although this result will be surprising to some, there are good reasons to expect the effect of vaccine mandates on mortality to be minimal.
First, evidence suggests COVID vaccine effectiveness against infection and transmission is much more limited than was originally hoped. Further, vaccination may induce behavioural effects that narrow the difference in risk between vaccinated and unvaccinated groups. For example, some research suggests vaccinated workers may take fewer precautions against infection or be less likely to notice symptoms when they do get infected.
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That said, it’s worth noting that finding no evidence for any effect on deaths isn’t quite the same as proving there’s no effect. We cannot completely rule out the possibility that the mandate had some impact on deaths among residents (either positive or negative) but that the effect was too small to show up as statistically significant in our data.
Also, lack of data meant we couldn’t test for any effect the mandate may have had on illness from COVID among care home residents.
What does this all mean?
Although the English vaccine mandate ended in spring 2022, legal mandates and restrictions imposed by employers are still common in a number of countries including the US, Canada and Australia.
A major concern when the English policy was introduced was that mandatory vaccination would lead to carers leaving the sector, exacerbating staffing difficulties. Our evidence confirms the mandate did have a significant effect in this regard.
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To date, policymakers concerned about a trade-off between the health of elderly care home residents and staffing of these care homes have had limited empirical evidence to draw on. There has been no attempt that we know of to use real-world data to estimate the effects of this mandate on vaccine uptake, staffing or deaths from COVID.
Even putting aside the serious the ethical issues involved, our research suggests policymakers would be wise to exercise caution before considering similar mandates in any future pandemic.
David Paton is a member of HART (Health Advisory and Recovery Team).
Sourafel Girma does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
