The UK transport minister, Grant Shapps, announced on 28 April 2021 that the UK government plans to use the existing NHS App to provide proof of covid-19 vaccination status for international travel. For many years, proof of smallpox, polio, and yellow fever vaccinations have been an entry requirement for many countries. The World Health Organization “yellow card” scheme has been in place since 1969, and proof of ACWJ meningococcal vaccine is required for Hajj to Saudi Arabia.
So while discussions on “vaccine passports” are old, the scale of the covid-19 pandemic will require a large number of global travellers to use a vaccine passport, which is an unprecedented development; and the technological options are far more advanced than for the previous paper-based certificates used for other vaccines. There are arguments for and against vaccine passports. We are facing a global pandemic, with huge variations in disease prevalence and vaccine mobilisation between countries. And while we watch the tragic scenes from India, many people in the UK are preparing for their first opportunity this year to visit oversees relatives or take an international holiday.
In a statement on 5 February 2021, the World Health Organization (WHO) laid down their reasons (at that time) for not supporting the idea of vaccine certificates; based on ethical, legal, scientific, and technological reasons. WHO recommends that people who are vaccinated should continue to comply with other risk-reduction measures when travelling. WHO also stated that their recommendations will evolve as vaccine supply expands and as evidence about the efficacy of existing and new covid-19 vaccines increases. This however has not deterred some countries—notably Israel—pushing ahead with their digital “Green Pass” scheme, with the USA also exploring options for vaccine certification.
Should the UK government decide to proceed with a vaccine passport policy, what method would we use? General practitioners, who are already struggling to meet unprecedented demands, while delivering around 75% of covid-19 vaccines thus far, cannot be expected to provide proof of vaccinations. There are digital solutions available such as the NHS App, or possibly the NHS Covid-App. Many UK patients nationwide already use their NHS App for a range of services including to seek medical advice, view their GP records, make appointments, submit secure electronic enquiries to their GP, and to order repeat prescriptions. It is also possible for people to use the App to view their covid-19 vaccination record. This area of the existing NHS App, already used by millions of patients, is clearly a safe and obvious place to use as a digital “vaccine passport.” Increased downloads and use of the NHS App by those using it as their “vaccine passport” could have additional long term benefits for patients and the NHS through encouraging use of other digital NHS services.
However, detailed medical record access—currently required to view vaccination records—is not enabled by default when you register with the NHS App. Proof of covid-19 vaccination status would therefore need to be separate from the rest of the medical record so that it can be enabled by default for everyone without the need for individual permissions from general practices. The covid-19 vaccination record can also sometimes appear in the acute medication section of the NHS App, but not usually with all details (such as vaccine batch number). This needs to be rectified so that the vaccination details are always in the same place in the NHS App. We would expect NHS Digital to rectify these issues before the NHS App is enabled as a covid-19 vaccine passport.
Covid-19 vaccination is recorded using the national PharmaOutcomes (also known as Pinnacle) IT system. NHS England decided to use this rather than recording directly into GP patient record systems because data can be entered using a web browser, and thus the system can be used across all vaccine sites, including those that have no access to GP medical record systems such as EMIS or SystmOne. However, some people have reported that the information on their vaccination is not always transferred to their GP medical record, and indeed GP Teams have also noted other discrepancies.
When inaccuracies are noted, covid-19 vaccination data must then be entered manually by the GP practice. This is not an ideal solution as errors and omissions in data recording can then occur, in addition to creating extra work for hard-pressed primary care teams. If the NHS App is to be used to confirm vaccination status, it is essential that all IT issues are resolved promptly to ensure the NHS App contains an accurate record of people’s vaccination status and extra work is not created for primary care teams.
An editorial in The BMJ discusses some of the wider practical and ethical issues in the implementation and use of vaccine passports; such as the need to ensure they do not further exacerbate current health inequalities. For example, many people in the UK do not own a modern smartphone capable of running the NHS App, a feature of the “digital divide.” This may be because they either cannot afford a smartphone or because they lack the technical proficiency to use one. This will affect older people and those from poorer sections of society; groups that already have lower levels of vaccine uptake, and higher levels of illness and poor health. The UK government’s proposal of using the NHS App may work for the majority of the population, but we must consider alternative options for those without access to suitable technology so they are not prevented from overseas travel.
There is debate for and against vaccine passports, which are being implemented by several countries already, but are not currently recommended by the WHO. The UK government’s proposal to use the NHS App to provide proof of covid-19 vaccination status is a practical and pragmatic solution for most UK citizens. However, we suggest that IT issues need to be addressed before we can rely on the NHS App as a “covid-19 vaccination passport,” to prevent extra bottlenecks and delays in airports. GP teams, who are already struggling for time, need to be protected from a tsunami of requests for certification to travel; and solutions also need to be found in case of technology failure, and for those unable or unwilling to use the NHS App.
Simon Hodes, GP Partner, Watford, UK
Azeem Majeed, Professor of Primary Care and Public Health, Imperial College London, London, UK
This article was first published by BMJ Opinion.