GUIDANCE ON PRESCRIBING VACCINATIONS ON THE NHS & PRIVATELY (INCLUDING TRAVEL VACCINATIONS)

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1 GUIDANCE ON PRESCRIBING VACCINATIONS ON THE NHS & PRIVATELY (INCLUDING TRAVEL VACCINATIONS) Under the new GMS contract (from 2004), vaccinations and immunisations are paid for through various mechanisms dependent on which services a GP wish to provide. Payment may be through the: i) global sum ii) directed enhanced services iii) quality and outcomes framework iv) private income for some travel vaccines. All vaccinations for patients whom are clinically indicated should be covered by the GMS contract. Although issuing a FP10 for vaccines covered in the GMS contract is not prohibited (not black-listed), the prescriber may need to justify the appropriateness of issuing an FP10 prescription where they were of the opinion that it was clinically indicated but for some reason the patient was not vaccinated under the national programme covered in the GMS contract. In this situation the patient should not be referred to have it privately. The prescribing of the vaccine will be charged to the practices prescribing budget.. There is unlikely to be a scenario in which a vaccine would be clinically indicated for a patient and they were not covered by the national programme under the NHS in the GMS contract, therefore a GP is unlikely to need to write a NHS prescription.

2 If a vaccine for a patient is not covered by the national programme under the NHS in the GMS contract and the GP feels it is not clinically indicated, but the patient insists on having the vaccine, then they may be able to obtain it privately. However, under the NHS regulations, GPs cannot charge NHS patients of their own practice for writing a private prescription, supplying or for administering without breaching their terms of service. Therefore, a GP may or may not wish to provide a vaccine privately where they are not charging for writing a private prescription or administering a vaccine, and the patient would need to obtain the vaccine from a pharmacy and pay for the vaccine plus an additional dispensing fee. The only exceptions to the rule above (in bold) are specified in Regulation 24, Schedule 5 of the National Health Service (General Medical Services Contracts) Regulations 2004 and include: i) travel vaccines not included in current public policy and travel packs ii)drugs solely in anticipation of the onset of an ailment while outside the UK. Further details on travel vaccinations are provided below. There is nothing in the GMS contract that prevents GP s in the case of nonregistered patients to charge to write private prescriptions, supply or administer vaccines that are not covered in the national programme under the NHS in the GMS contract. The important point is that if GP s do prescribe such vaccines privately, there must be no compromise to the NHS services which would then become a contractual issue, therefore it would be necessary to have assurances that the service/consultation is not done in NHS time. Examples: 1) HPV- is a school age programme, administered within schools, and not available to GPs to give. Also, GPs are not commissioned to administer so cannot claim any payments. The Department of Health criteria is for all year 8

3 girls to be offered, and there was a catch-up in 2009/10 for all girls up to their 18th birthday. A GP may prescribe or administer the HPV vaccination privately but they are not allowed to charge to prescribe, supply or administer a registered patient under the NHS. Therefore a GP may wish to refer any older girl needing to access the HPV vaccination to a private provider which may be another GP practice. 2) Single MMR vaccinations- Single vaccines for measles, mumps, or rubella are not specified in Schedule 5 of the regulations and continue to not be recommended by the Department of Health. A GP may prescribe or administer the vaccinations privately but again cannot charge their NHS patients for prescribing, or for administering these vaccines without breaching their terms of service. Therefore GP s may wish to refer patients to a private provider of single MMR vaccinations. 3) Shingles vaccine- Zostavax is currently not available on the NHS and Sanofi Pasteur are in negotiations with the DOH for a national programme. However, there are insufficient supplies of Zostavax available currently to meet the needs of a nationwide vaccination programme. The company concluded that the only viable option at this time is to make the doses available through private prescription, as universal distribution through the NHS is not yet possible. Based upon their clinical judgement, GPs caring for NHS-registered patients can write a private prescription for the shingles vaccine, if they believe it will be of benefit. However, under the regulations GPs may not charge patients for the prescription or for administering the vaccine and patients will need to pay for the vaccine plus an additional dispensing fee, to obtain it from a pharmacy. Alternatively, GP s may wish to refer patients to a private provider. Although Zostavax is licensed in adults over the age of 50 years, the Joint Committee on Vaccination and Immunisation (JCVI) has recommended the introduction of a shingles vaccination programme for people aged years.

4 TRAVEL VACCINATIONS There are three categories of travel immunisations: 1. Travel immunisations that must be given as part of NHS provision though GMS Additional Services The following immunisations for travel are part of Additional Services under GMS3 and PMS and no fee may be charged by the contractor to a patient registered for NHS services with that contractor: Hepatitis A [infectious hepatitis] - first and second/booster dose (6-12 months after first dose) all doses Typhoid - first and any booster doses5 Combined hepatitis A and typhoid - first dose (second dose is with Hepatitis A alone) Tetanus, diphtheria and polio as given in the combined Td/IPV vaccine6 Cholera 2. Travel immunisations that cannot be given as an NHS service The following immunisations are not prescribable as part of NHS services and are not remunerated by the NHS as part of additional services: Yellow Fever

5 Japanese B encephalitis Tick borne encephalitis Rabies The contractor may therefore charge a patient registered for GMS/PMS/APMS services for the immunisation if requested for travel. The patient may either be given a private prescription to obtain the vaccines, or they may be charged for stock purchased and held by the practice. The process of administration of the immunisation is chargeable as well. Practices should also give the patient written information on the immunisation schedule proposed and the charges involved at the outset of the process. An FP10 (or equivalent NHS prescription) must not be used to provide these vaccines. 3. Travel immunisations that can be given as either NHS or as a private service The following immunisations for travel are not remunerated by the NHS as part of additional services and are in this category: Hepatitis B (single agent) any dose Meningitis ACWY (quadrivalent meningococcal meningitis vaccine; A, C, Y and W135) This category is the one that causes most confusion. The ambiguity in this section stems from the regulations regarding the charging of patients that are registered with the practice. Schedule 5 of the NHS regulations states that:

6 The contractor may demand or accept a fee or other remuneration. for treatment consisting of an immunisation for which no remuneration is payable by the Primary Care Trust and which is requested in connection with travel abroad This wording leaves the decision as to whether the practice levies a charge or not to the discretion of the practice. The regulations do not impose any circumstances or conditions as to when these immunisations should be given on the NHS or as a private service. In some areas local policy has been agreed with the LMC that seeks to exclude NHS provision, and practices should consider any such local policies. Most practices provide hepatitis B as part of a combined A+B vaccination rather than as a single agent, and this has been the focus of local attention. Ultimately the decision still resides with the practice. We would remind practices that there is no funding within GMS for hepatitis B for travel. Practices therefore need to be clear about their policy to avoid falling foul of regulations that prohibit charging NHS registered patients. The service must be provided either entirely as an NHS process or entirely as a private service, and the following paragraphs illustrate that difference. To provide this as an NHS service, the practice would either prescribe the immunisation on an FP10 (or national equivalent) or (in England and Wales) provide the vaccine from purchased stock and claim reimbursement through the normal channels (in the same way as immunisations provided under additional services). The practice must not charge the patient for the administration of the vaccine. If a confirmatory certificate is requested by the patient then the practice may charge for this, but cannot charge just for recording immunisation details for the patient s personal record. Alternatively the practice may decide provide this as a private service and charge a patient registered for GMS services for the immunisation. In this situation this can either be provided on a private prescription or the patient charged for the supply from practice stock. In this situation a charge may be made for the administration of the vaccine.

7 It is important to avoid mixing these two scenarios. If these immunisations are provided as an NHS service, then no charge can be made to the patient other than for certification if requested by patient (which is not compulsory). Practices also have to ensure that their policy is non-discriminatory and that this is not done contrary to the Equality Act 2010 (formerly the Disability Discrimination Act). References 1.DoH Green book. Available at 2. GMS Regulations (Schedule 2, paragraph 4 and Schedule 5, paragraph 1 (g)): Available at: (parallel arrangements for PMS/APMS and in devolved nations). 3. BMA advice on vaccinations and immunisations. Available at: andimms0404.jsp