Doctor placing plaster on patient's arm after vaccination

The inside story of how England’s COVID-19 vaccination booking system was built in just weeks

As the COVID-19 pandemic began to take hold of the UK in early 2020, the thought of a vaccine being successfully and safely developed by the end of 2020 seemed beyond optimistic. And yet, on December 8, 2020, the first non-clinical trial Pfizer-BioNTech vaccine was administered — just eight-and-a-half months after the UK’s first lockdown.

Today, more than 125 million COVID-19 vaccination doses have been given to people in England, with more than 33 million people having at least three doses. With a phased rollout based on clinical vulnerability, the UK’s vaccine deployment was among the fastest in the world, with one of the highest uptake levels in its first few months.

In England, the NHS’s efforts to encourage people to receive the COVID-19 vaccine were supported by a number of companies that use tools and services powered by Microsoft’s Azure cloud platform. With this support, vaccinations were offered and administered across the country in a timely, efficient and reliable manner. Their services are still being used to effectively combat the pandemic today.

An unprecedented society-disrupting global pandemic, combined with the urgent need for vaccine administration on a scale beyond anything previously required, meant that multiple systems needed to be deployed and link seamlessly with each other as soon as the vaccines were ready. The NHS’s speed, agility and commitment to technology in the process continues to save lives to this day.

Building the backbone

A key part of NHS England’s vaccine strategy is NHS Digital’s National Booking Service, the national online system which enables members of the public to book COVID-19 vaccinations at vaccination centres and community pharmacies. Underpinning the booking system lies the National Immunisation Management System (NIMS), an Azure-based solution that has been developed by an alliance of three companies – System C Healthcare, Graphnet Health and Liquidlogic.

Playing a crucial role in the vaccination rollout, NIMS is a single database that contains a near-real-time view of vaccination eligibility and vaccination event records for the population of England. This information is used to identify which patients are a priority for vaccination, what vaccinations are recommended for those patients, as well as recording the type and number of vaccines that people have had. The service went live on September 1, 2020, to manage the 2020-21 influenza immunisation season, before being utilised for the management of COVID-19 vaccinations on December 1, 2020.

Given the sensitivity of the information stored in NIMS, all data held within the service is within the UK jurisdiction, hosted in Microsoft’s secure and compliant Azure cloud, within Microsoft’s UK-based data centres. Importantly, Microsoft has no access to the data.

Scheduling vaccinations

England’s initial vaccination rollout saw the Government announce its priority-based order for which groups of people would be receiving the vaccine, using key criteria such as age, occupation, and vulnerability based on other health conditions.

An online system was also needed to allow people to book coronavirus vaccination appointments at vaccination centres across England. This would become the National Booking Service. In order to scale the delivery of the National Booking Service, NHS Digital called on the services of Accenture and Avanade, 16-time winner of Microsoft Partner of the Year, to provide cloud native delivery skills.

To ensure that only eligible people could receive the vaccination, the National Booking Service needed to assess and then accurately accept or reject people’s vaccine booking attempts based on their eligibility within seconds. It also had to keep track of how many vaccines individuals have had, and when subsequent ones have been booked. In order to build confidence in what Dr Nikki Kanani, Medical Director of Primary Care for NHS England, called “the biggest vaccination drive in health history”, the system had to do all this seamlessly while handling the immense pressure and load of millions of people trying to use it at once. The Azure-based Q-Flow system, which had been implemented by ACF Technologies and supports the National Booking Service, was the selected solution.

The UK’s vaccine deployment was among the fastest in the world, with one of the highest uptake levels in its first few months

Plugging into the NHS patient data securely held in NIMS, the booking system quickly accepts or rejects people’s vaccine booking attempts based on their eligibility. Once approved, patients can then book their vaccinations at nearby vaccination centres, receiving confirmations and reminders via email or in a text message. Given the sheer demand faced by tens of thousands of people trying to book appointments at the same time, the National Booking Service also has a built-in queuing system, which provides patients with their position in the queue and an estimated time until they can book their vaccine appointment. If that isn’t an impressive workload for one system to handle, the Q-Flow system is also used by vaccination centres to register and open new locations, as well as oversee the checking in of patients and staff logins.

Naturally, given the importance of such a system, the risk of failures such as crashing due to high demand needed to be eliminated as much as possible. Azure’s stability and ability to increase or decrease capacity depending on demand, proved critical. “What we really needed from Azure was its instant ability to flex,” says Simon Ronald, vice-president of business development at ACF Technologies.

“We started the project with the Government saying that there could be 20 million patients a week going through our system. But in the beginning, when the first 100 vaccination locations were being deployed, we didn’t need to support that many bookings. But then, of course, things ramped up, to the point where we were processing up to 500,000 bookings an hour. So Azure’s instant ability to flex and scale-up is absolutely key in making sure the system holds up in peak periods. We need to be confident that we’re using a platform like Azure that can survive an unknown amount of demand.”

The tools provided by Azure allowed us to develop and deploy a project that was bigger than anything we’ve ever done before, in such a short space of time.

– Simon Ronald, vice-president of business development at ACF Technologies

According to Ronald, developing a significant component of the vaccination booking system of this scale and complexity would normally take up to 10 months. But the country couldn’t wait that long. Millions of people were relying on this system to protect themselves and their loved ones from a potentially deadly virus. The ACF team knew what was at stake. In partnership with the main development team in NHS Digital, they worked long hours and weekends to build the project out in just four weeks. The vaccination booking system worked flawlessly, allowing millions of people to receive their jabs.

“The tools provided by Azure allowed us to develop and deploy a project that was bigger than anything we’ve ever done before, in such a short space of time. Given the crunch, you’d expect a certain level of risk that would lead to problems developing. But there was none. We didn’t come across any issues.”

Empowering GPs

While the National Booking Service handles appointments at vaccination centres and community pharmacies, most GP practices set up and managed separate vaccination clinics for their patients.

GPs messaged eligible patients to tell them they met the conditions to book a vaccination and encouraged them to make an appointment. This required another digital solution.

This system was powered by accuBook, a system developed by Accurx – a British software company specialising in healthcare communication whose products are used by more than 98 per cent of GPs in England to communicate with patients using video calls, surveys, digital documentation and more.

In November 2020, sensing the critical role that GP practices would play in delivering the COVID-19 vaccinations, Accurx used Azure to build its vaccination booking solution in just four weeks.

This incredibly quick development displays not only the flexibility of Azure but the drive of the people working to deploy a vitally important product that would help save lives. Once complete, the system enabled GP practices to upload a file containing patient information, which was then checked against the NIMS database to automatically mark those eligible for the vaccine. The system then allowed GPs to automatically contact all eligible patients via text messages, letting them book their vaccinations directly via their GP. The system saved staff from having to manually go through patient records to notify those eligible for vaccination via a letter or phone call – a task that would have been simply unfeasible given the scope and ever-changing nature of events at that time.

Laurence Bargery, CTO and co-founder of Accurx, says: “We were shipping products and moving faster than we had ever done before. The fact that at the flick of a switch we could scale our database, our web servers and release so quickly was a huge factor in our success. In addition, Azure has lots of great ways to keep data safe and secure, including granular permissions access to Azure resources or resource groups, automatic detection systems for suspicious behaviour, and using KeyVault to secure information.”

To date, almost 29 million vaccines have been booked and managed via accuBook. More than 5,000 GP practices have used accuBook, which at the peak of the vaccine drive was handling up to 300,000 bookings a day.

Overall, the security, scalability and reliability of these Azure-powered solutions across these different entities have enabled millions of people to swiftly book their COVID-19 vaccinations as soon as they became eligible to do so. This has saved lives, reduced stress for patients coping with their life being turned upside-down during the pandemic, helped reduce the pressure on the NHS and saved frontline healthcare staff countless hours.

“Seeing all of these hardworking people from three different organisations come together in such a short period of time and delivering, collectively, while the world was on lockdown, gives us a lot of pride,” Bargery reflects.