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Paying for the Flu Vaccine

By Ben Davies

As I do every winter, I recently booked an appointment for a flu vaccine. I get it for free in the UK. If I didn’t have asthma, I’d still get vaccinated, but it would cost me between £9 and £14.99. That is both an ethical error on the part of the government, and may be a pragmatic one too.

There are a number of ways to qualify for free flu vaccination in the UK. Some of these are centred around personal vulnerability, such as age (over 50s and most school children); certain health conditions; or pregnancy. Others concern proximity to those who are vulnerable and include carers; frontline health and care workers; and co-habitation with a person at heightened risk. Curiously, though, simply living with someone in the first category doesn’t appear to be enough to qualify you; the NHS website mentions conditions where people are at considerable risk from infection, such as HIV, post-transplantation, or certain treatments for conditions such as cancer.

I’m going to offer an argument for the flu vaccine being provided free to everyone who is eligible. But first, I’ll make a less demanding argument, which is that the current exemptions don’t go far enough. Even if you don’t think that a 30-year-old with no serious medical conditions and no immediate links to vulnerable people should get a free jab, you might still agree with this initial argument.

One main gap in the payment exemptions list is poverty. As Neil Ferguson puts it in a Lancet article from around 15 years ago:

History tells us that poor populations always endure a disproportionate burden of disease and death from infectious diseases.

Not only that, but poverty is also clearly going to be correlated with a lack of ability to pay. £9 is a sum that many of us can afford quite easily. But for those on limited incomes that have just become more limited, £9 (or more in a family with multiple, non-eligible adults) represents an expenditure that would make it very tempting to risk not getting vaccinated.

Other extensions to the free-vaccine list could be argued for. But it also seems strange, particularly this year, that anyone is being charged for the flu jab. As we know from the past couple of years, those who are at low risk of death, hospitalisation and serious illness can still spread infectious diseases. They are also, for obvious reasons, less likely to get vaccinated. In England, the percentage of each age group who have taken up Covid vaccinations increases almost uniformly with age, the only exception being the fact that 18-24 year olds have slightly higher uptake than the 25-29 group.

There have been considerable warnings already that restrictions designed to limit the spread of Covid have also had a significant effect on other diseases, and that where restrictions have mostly been lifted (which includes the UK), we should expect a considerable jump in flu cases, as well as the possibility of people becoming infected with both Covid and the flu simultaneously. Whatever your view on whether restrictions should have been lifted in the UK, when vaccination rates even among those eligible for a free vaccine are not as high as they might be, it is hard to see any argument against doing everything we can to stop transmission of what may be a particularly virulent flu this winter.

In fact, I think this argument applies more generally; we shouldn’t be charging people for flu vaccinations at all. Annual flu deaths vary considerably, but it isn’t that long since we saw a year where over 20,000  deaths were associated with flu, in 2017-18. Even if we think that those who can afford it ought to be prepared to pay to get vaccinated, if many of us won’t pay the costs of that decision go far beyond an effect on our personal health. Of course, making the vaccine free won’t motivate everyone to get it; government should also be promoting vaccination and making it easier to access, especially for those in the  most vulnerable groups. But removing the up-front cost is a good place to start.

What’s more, implementing universal free access links back to my initial argument around expanding the exemption list to cover poverty. If we want those on very limited incomes to take up vaccination, we should want to avoid both stigmatisation and psychological barriers. For those without exemptions on other bases, having to prove that you are suffering financial hardship (or even worrying that you will have to prove this) may itself be a psychological barrier to seeking vaccination.

Writing in January 2019 (so, before Covid), Jeremy Brown notes that the JCVI has deemed funding vaccination for “young, healthy adults” not cost-effective.* But, at least on Brown’s telling, this seems to be based on the direct effects of flu on that population, i.e., on the fact that young, healthy adults don’t tend to get very ill from the flu. And of course, it’s easy to call for an increase in spending when I’m not the one who has to worry about where that money will come from. Still, at least as Brown tells it this ignores both the broader economic costs of flu among healthy adults, and the potential for vaccination to reduce transmission.

Is this latter factor is fully costed into the JCVI’s recommendations? I’ve been unable to find out from various government documents. If it isn’t, it should be. If it is, that might speak against a ‘free-for-all’ vaccine in most years (though the argument around extending the exemption on the basis of ability to pay still applies). But this year, where we seem to be heading towards the possibility of another extremely difficult winter for the NHS, there seems to me to be a good case for bringing down levels of flu as much as possible. And even if there are good reasons against dropping charges altogether, the exemptions need to be widened.

*Thanks to Fiona Woollard for pushing me on this following the original version of this blog.

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