GUIDANCE ON PAYMENTS FOR VACCINATIONS AND IMMUNISATIONS Version: Ratified by: Date ratified: Date issued: Expiry date: (Document is not valid after this date) Review date: Lead Executive/Director: Name of originator/author: Target audience: Final PCT Professional Executive Committee 28 th August 2009 1 st September 2009 31 st March 2012 January 2012 Dr. Richard Harling Sue Bosworth/Sue Lunec All medical / non-medical prescribers and clinicians in general practice.
CONTRIBUTION LIST Key individuals involved in developing the document Name Dr Ash Banerjee Sue Bosworth Sue Lunec Designation Consultant in Public Health Primary Care Services Development Manager Senior Pharmaceutical Advisor [Provider Services] Circulated to the following individuals for comments Name Designation Lynda Dando Head of Primary Care Commissioning Jane Freeguard Head of Medicines Management and Pharmacy Anne Kingham Senior Pharmaceutical Advisor [Primary Care] Dr Simon Parkinson Local Medical Committee Secretary Dr Alan Tweddell Consultant in Health Protection [Health Protection Agency] Members of the Professional Executive Committee Page 2 of 16
CONTENTS Key individuals involved in developing the document 2 Circulated to the following individuals for comments 2 1 Introduction 4 2 Aims of guidance 4 3 Occupational Health Services 4 4 Patient Group Directions 4 5 Patient Specific Directions 4 6 Travel vaccinations 5 6.1 Travel vaccines obtained for NHS use 5 6.2 Travel vaccines for private use 5 6.3 Travel advice 5 6.4 Malaria prophylaxis 6 6.5 Taking medicines out of the UK 6 6.6 Prophylactic medicines 6 7 Other Vaccinations 7 8 Reciprocal Agreements 7 9 Vaccine storage 7 10 Additional information 7 11 Bibliography 8 12 Acknowledgements 8 13 Guidance on immunisations and vaccinations [Table 1] 9 Page 3 of 16
1 INTRODUCTION The Green Book Immunisation against infectious diseases gives Department of Health [DH] advice on the circumstances when patients should be offered a vaccination. This does not necessarily mean the vaccines should be offered under the NHS. The purpose of this document is to clarify situations where vaccines may be given free of charge under the NHS, when patients should be charged and other fees available to GPs. 2 AIMS OF GUIDANCE The aim of the guidance is to provide advice on the provision of vaccination in the following circumstances: Where vaccination is covered under essential services provided by the contractor under a global sum/baseline payment and no charge should be made to the patient. Where vaccination is covered under an enhanced service agreement and a Directed Enhance Service [DES] or a Local Enhanced Service [LES] has been agreed with the contractor, no charge should be made to the patient. Where travel vaccination is provided as a private service and where contractors may charge the patient directly for the service provided. Where vaccination is available only as a private service but where contractors may NOT charge patients directly but can refer to another provider i.e. another GP practice or private clinic [see 8-Reciprocal Agreements and Table 1]. 3 OCCUPATIONAL HEALTH SERVICES GP Practices cannot provide occupational health services to their own patients and charge the patient. The patient should be advised that it is not the responsibility of the practice to provide this under the NHS. This includes the provision of Hepatitis A or B vaccination for occupational purposes for medical and nursing students. The immunisation should be given under the employer s or university s private occupational health scheme. The employer may negotiate a private contract with a private clinic or a GP practice to undertake an occupational health programme. 4 PATIENT GROUP DIRECTIONS [PGDs] GP practices with an NHS contract may use PGDs developed and approved by their Primary Care Trust [PCT] for vaccinations provided under the NHS. PCT PGDs may not be used for vaccinations given privately. Therefore, Worcestershire PCT [NHS Worcestershire] will be withdrawing PGDs currently used for Rabies and Meningococcal ACWY. Practices may not produce their own PGDs for these purposes. This means for private vaccinations Patient Specific Directions must be used. 5 PATIENT SPECIFIC DIRECTIONS [PSDs] This is where a GP or non-medical prescriber directs a suitably qualified and fully competent health care professional, who is employed by the practice, to administer the vaccine. Prescribers must individually assess patients for their suitability for the vaccine. Page 4 of 16
6 TRAVEL VACCINATIONS Some travel vaccines are included in the global sum/baseline payments and GP practices may not charge patients for administering them. Neither is there an additional fee available from the PCT. Practices may charge patients for the purchasing and administering of the vaccines that are not included in the global sum. The old Item of Service Red Book payments are now incorporated in the Global Sum payments for all GP practices whose contract includes the provision of vaccinations and immunisations. Any Practice opting out of the ngms additional vaccines and immunisations service provision will not be able to charge their registered patients for travel vaccines which are available on the NHS. 6.1 TRAVEL VACCINES FOR NHS USE 6.1.1 Purchased by the practice and reimbursement through FP34PD or FP10 via the Prescription Pricing Division [PPD]. 6.1.2 Obtained by the patient on FP10 prescription issued by the practice. A prescription charge is payable to the pharmacy unless the patient is exempt. In this situation no claim for personal administration fees may be made through FP34PD. See table one for details of remuneration. 6.2 TRAVEL VACCINATION AS A PRIVATE SERVICES The DH recommends that vaccination against diseases that are not likely to be transmitted to others on the traveller s return should be paid by the patient. This is a private service and charges may vary between GP practices. Patients should usually expect to pay a charge for the cost of the vaccines, the issue of the prescription and a fee for administration of the vaccine by the healthcare professional. Practices should develop a protocol outlining the practice charges for private travel services that are available to patients. A list of charges should be clearly displayed within the practice. Patients should also be reminded of any charges prior to the vaccination being given to ensure that there is no misunderstanding as to the fees charged. Practices may keep vaccine stock items and may charge the patient for the cost of the vaccine/medication directly or practices may prefer to provide a private prescription and ask the patient to take this prescription to a community pharmacy who will supply the vaccine to the patient. Vaccine should be purchased by the practice from a wholesaler, community pharmacy or directly from the vaccine company. 6.3 TRAVEL ADVICE charge may be made to any registered patient for providing travel advice. Travel advice represents appropriate health promotion for patients wishing to travel abroad and therefore is classed as an essential service within the current GP practice contract. It is also unacceptable for practices to charge a fee for the administration of travel vaccinations available on the NHS. Page 5 of 16
6.4 MALARIA PROPHYLAXIS Antimalarials should not be prescribed on the NHS for prophylaxis. Guidance relating to this matter was issued by the DH in 1995 [FHSL [95] 7]. The guidance states that when a prescription only antimalarial is required [Mefloquine, Malarone or Doxycycline] the prescriber should issue a private prescription. GP practices may charge the patient for issuing the prescription if they wish. The charge should be made in line with the practice s standard charge for issuing a private prescription. FP10 prescription forms should not be used. Dispensing doctors should not claim any reimbursement from the PPD on FP10 for drugs for malaria prophylaxis provided to patients. 6.5 TAKING MEDICINES OUT OF THE UK Patients should be advised to find out if there are any restrictions on taking out medicines, either prescribed or bought from a pharmacist or other over the counter facility, in and out of the UK or the country they will be visiting. This information can be obtained from the relevant Embassy, High Commission or the Home Office Drug Branch. An NHS patient travelling abroad may ask their GP practice for a FP10 repeat prescription to cover their time abroad. This is at the discretion of the practice but must be for no longer than 3 months. This should give patients enough medication to last until they can make alternative arrangements for supply in the country they are visiting. The DH recommends that the period for which prescriptions should be issued is best decided by the patients GP, taking into account their detailed knowledge of the patient s medical history and current condition. When a doctor prescribes a drug they are clinically and legally responsible for any results of that decision to prescribe. In view of this it would not be considered good clinical practice to prescribe large amounts of medicines to a patient going abroad for an extended period of time, whose progress the GP is not able to monitor. Relevant information for travellers with pre-existing medical conditions can be obtained from the Travax website [for health professionals only] www.travax.nhs.uk or via www.nathnac.org or www.hpa.org.uk or the relevant patient groups. 6.6 PROPHYLACTIC MEDICINES Where a patient is required to have medication in their possession solely in anticipation of the onset of an ailment whist they are outside the UK, but for which they do not require treatment when the medicine is prescribed, the patient should be given a private prescription. GP practices may wish to charge the patient for issuing a private prescription; paragraph 38 of the GP terms of service defines the circumstances in which GPs can charge patients a fee for supplying a private prescription. The most common reasons are for prescription for anticipation of illness abroad i.e. antiemetics or antibiotics, prevention of altitude sickness and malaria chemoprophylaxis [see above]. Page 6 of 16
7 OTHER VACCINATIONS For full list see Table One. Childhood immunisations covered under the NHS global sum/baseline payments for all GP practises whose contract includes the provision of vaccinations and immunisations. Childhood vaccinations with the exception of pneumococcal [PCV] / Hib/MenC / HPV are covered in the global sum/baseline payments which are automatically provided to GP Practices. At present, exceptions to the routine childhood vaccinations may be claimed via the enhanced services claim form for children within the age groups. Enhanced service payments may be claimed if the following criteria are met: The practice is contracted to provide the childhood immunisation and pre-school booster additional service. The patient is on the practice list at the time the final and completing vaccination is administered. The practice administers the final and completing dose. The practice does not receive any payment from any other source in respect of the vaccination given. Practices are requested to submit claims within six months of administering the final and completing dose. Where vaccine is supplied and delivered free of charge through the NHS centrally purchased vaccine scheme no charge or claim may be made by the practice. 8 RECIPROCAL AGREEMENTS GPs should be aware that a reciprocal agreements between practices is a restrictive practice and could be deemed as price fixing and fall foul of competition law. A patient wishing to purchase a private service is free to use any provider. 9 VACCINE STORAGE Vaccines should be stored according to the manufactures recommendations. In the event of refrigerator failure seek the manufactures advice on the efficacy of the vaccine before consigning the stock as waste. For further information with regard to the cold chain and storage of vaccines see The Green Book and the PCTs vaccination and immunisation guidelines. 10 ADDITIONAL INFORMATION Information on individual immunisation schedules can be accessed on; www.travax.nhs.uk for health professionals only http://www.bma.org.uk/ www.dh.gov.uk/en/publichealth/healthprotection/immunisation/greenbook/dh_4097254 www.nathnac.org www.nhs.uk/healthcareabroad/pages/healthcareabroad.aspx www.hpa.org.uk www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidance/dh_079917 www.patient.co.uk/showdoc/26740167/ www.nhsbsa.nhs.uk/prescriptionservices/933.aspx www.portal.nelm.nhs.uk/pgd www.fitfortravel.scot.nhs.uk patient information on general travel health advice, malaria prophylaxis and travel vaccinations. For complex itinerary enquires, healthcare professionals may contact the following specialist centres: Royal Free Travel Health Centre 020 7830 2885 Malaria Reference Laboratory 020 7636 3924 Page 7 of 16
11 BIBLIOGRAPHY Health Service Circular HSC 1999/018 Schedule 10 to NHS [General Medical Services] Regulation 1992 Schedule 11 to NHS [General Medical Services] Regulation 1992 Health Information for Overseas Travel The Yellow Book HMSO 2001 World Health Organisation International Travel and Health MIMS Companion Spring 2002 General Medical Services Good Medical Practice www.gmc-uk.org/ Department of Health; FHSL (95)7: Malaria prophylaxis regulation permitting GPs to charge for prescribing or providing anti-malarial drugs General Practitioners Committee Information and Guidance on Prescribing in General Practice, Sept 2004 Focus on vaccinations and immunisations BMA www.bma.org.uk/ap.nsf/content/focusvacc&imms0404 Department of Health supported Website for Patient Group Directions 12 ACKNOWLEDGEMENTS Hastings and Rother and East Sussex Downs and Weald PCTs Kent Local Medical Committee Page 8 of 16
Immunisations and vaccinations Table One Vaccination Comment PGD Payment, claim or fee available Global sum/base-line Enhanced fee FP10/ FP34D Private fee Anthrax Used for occupational high-risk groups only. Contact local HPA for advice. Vaccine supplied by HPA Porton Down. See page 4 occupational health services. Fee available for administering the vaccine. BCG BCG may be required for previously unvaccinated, tuberculin-negative individuals according to the destination and nature of travel. Refer to TB nurse and/or local chest physician. Immunisation should not be given under NHS by GPs in Worcestershire. PGD only available for TB nurses Cholera [Dukoral ] There is currently no requirement for cholera vaccination for international travel. May be considered for disaster aid workers or patients with remote itineraries in areas where a cholera epidemic is occurring and access to medical care is limited. Supplied under NHS if certain criteria are met and agreed with PCT Public Health and/ or HPA FP10 Travellers who do not meet criteria a private fee should be levied. Diphtheria [available as combined with Tetanus and inactivated Polio vaccine Td/IPV] [Revaxis ] Usually part of childhood immunisation. Revaxis is supplied free to the NHS for childhood immunisation only. Where diphtheria vaccination is required for travel to endemic areas. See Green Book and latest advice from CMO. administered under the NHS. See page 5 Vaccines obtained for NHS use. Revaxis for adults/travel may be purchased directly and FP34D submitted to PPD or FP10 issued. Page 9 of 16
Vaccination Comment PGD Payment, claim or fee available Global sum/base-line Enhanced fee FP10/ FP34D Private fee Hepatitis A [infectious hepatitis] Recommended for travelers to areas of poor sanitation and where the degree of exposure to infections is likely to be high. See Green book and latest advice from CMO. administered under the NHS if travel criteria is met. If vaccine purchased FP34D to PPD If vaccine administered as part of an outbreak control [on the advice of HPA] enhanced fee may be available if agreed with PCT. If vaccine purchased FP34D to PPD Hepatitis A vaccination should not be provided for occupational health reasons other than under contract with occupational health departments [See page 4]. Hepatitis A & B Combined [Twinrix ] t normally used for travel vaccination, as hepatitis B vaccination is not routinely required for travel use. In the few limited cases where hepatitis A&B [see under hepatitis B] is required the combined vaccine may be used. administered under NHS for limited cases if certain criteria are met. If vaccine purchased FP34D to PPD. If charge is levied to patient, vaccine must not be claimed on FP34D. Travellers who do not meet the criteria [see Hepatitis B] a private fee should be levied for the vaccine and its administration. Hepatitis A & Typhoid Combined [Hepatyrix /ViATM ] Advised where sanitation is primitive and where the degree of exposure to infection is likely to be high. See Green Book and latest advice from CMO. administered under the NHS. If vaccine purchased FP34D to PPD. If charge levied to patient, vaccine must not be claimed on FP34D. Travellers who do not meet the criteria and request vaccination a private fee for the vaccine and its administration should be levied. Page 10 of 16
Vaccination Comment PGD Payment, claim or fee available Global sum/base-line Enhanced fee FP10/ FP34D Private fee Hepatitis B Immunisation may be provided under NHS for the following groups : Babies born to mothers who are chronic carriers of hepatitis B virus or to mothers who have had an acute hepatitis B during pregnancy. Injecting drug users [Hep A&B]. Individuals who change sexual partners Frequently [Hep A&B]. Close family contacts of a case or carrier. Families adopting children from countries with a high prevalence of hepatitis B. Haemophiliacs [Hep A&B]. Patients with chronic renal failure. Patients with chronic liver disease [Hep A&B]. Children born outside the UK who have received a primary dose in their country of origin and who are now domiciled in the UK should have their course of the vaccine completed under GMS. Hepatitis B vaccination is not routinely required for travel use. Immunisation may be provided for the following groups of travellers to areas of high endemicity: - Who are at risk due to sexual activity, injectable drug use or contact sport. - Who intend to seek employment as healthcare or aid workers. - Who will be travelling/residing in these areas for 3 months or longer. and therefore may be at risk from acquiring infection as a result of medical or dental procedures carried out in those countries. HepB for travel PGD withdrawn administered under NHS for limited cases if certain criteria are met. Should not be provided under NHS if the patient does not fall into the risk groups If vaccine purchased FP34D to PPD If charge is levied to patient, vaccine must not be claimed on FP34D. If patient requests vaccination for travel a private fee should be levied for the vaccine, administration and blood test to confirm immunity. Page 11 of 16 Cont.
Vaccination Comment PGD Payment, claim or fee available Global sum/base-line Enhanced fee FP10/ FP34D Private fee Hepatitis B cont Hepatitis B vaccination should not be provided for occupational health reasons See page 4 other than under contract with occupational health departments this includes vaccination for occupational purposes for medical and nursing students [see page 4]. HIB Asplenic children and adults. For childhood vaccination schedule see Green Book and latest advice from CMO. administered under the NHS. Human Papillomavirus [HPV] Cervarix vaccination available to girls identified as part of the NHS vaccination programme. Vaccine supplied free to the NHS for eligible patients. administered under the NHS. Enhanced service fee available for eligible patients. For childhood vaccination schedule see Green Book and latest advice from CMO. Patients who fall outside the NHS programme and request the vaccination this should be provided as a private service. The patient should be directed to a facility offering that service. PSD Private fee levied to the patient for the provision of vaccine and administration. GP practices may not provide a private service for HPV vaccination and charge their patient. Page 12 of 16
Vaccination Comment PGD Payment, claim or fee available Global sum/base-line Enhanced fee FP10/ FP34D Private fee Influenza Immunisation offered under the NHS on an annual basis for those aged 65 yrs and over or those aged under 65 yrs in a risk category [see latest advice from CMO]. If vaccine purchased FP34D to PPD. Enhanced service fee available for eligible patients. Patients should not be charged for flu vaccination if part of NHS service. Patients who fall outside an at risk category and request the vaccination as a private service may be directed to a facility offering that service e.g. private clinic, community pharmacy or another practice. GP practices may not provide a private service for influenza vaccination and charge their patient. If a charge is levied to the patient, the vaccine must not be claimed on FP34D. Practices offering private service outside the NHS a charge may be levied to the patient for provision of vaccine and administration. Japanese Encephalitis Available directly from the manufacturer on a named patient basis. A private fee should be levied for the vaccine and its administration. Malaria [chemoprophylaxis] See information above on page 6. A private prescription / fee should be levied. Meningococcal [C] Adults entering full time education at college or university who have not previously received the vaccination [Meningococcal C] Group C conjugate element only administered under NHS If vaccine purchased FP34D to PPD. Asplenic Patients. [Use Hib/MenC vaccine] Hib/MenC PGD For childhood vaccination schedule see Green Book and latest advice from CMO. Page 13 of 16
Vaccination Comment PGD Payment, claim or fee available Global sum/base-line Enhanced fee FP10/ FP34D Private fee t available under NHS for travel. More ACWY Meningococcal prevalent in some areas of Africa and If charge is levied PGD administered under [ACWY] Asia. Travellers who work or live with to patient, withdrawn NHS where appropriate local people or backpackers are vaccine must not particularly at risk. be claimed on FP34D. Verification of vaccination may be required as entry requirement to Saudi Arabia for Hajj and/or Umrah pilgrimages. If patient requests vaccination for travel a private fee for the vaccine and administration together with any verification of immunisation that may be required should be levied. Measles Mumps and Rubella [MMR] For childhood vaccination schedule see Green Book and latest advice from CMO. administered under the NHS. Inactivated Poliomyelitis vaccine [only available as combined Td/IPV] [Revaxis ] Reinforcing immunisation provided to those with incomplete vaccination history see Green Book and latest advice from CMO. Where polio vaccination is required e.g. where a previous dose was given more than 10 yrs ago, a booster of combined Td/IPV should be used. This should not be necessary for travellers who are up to date with all vaccines as part of the standard immunisation schedule. For childhood vaccination schedule see Green Book and latest advice from CMO. administered under NHS FP10 Vaccine supplied free to NHS for child immunisation. Pneumococcal [PCV] Part of the routine childhood vaccination schedule see Green Book and latest advice from CMO. administered under NHS Enhanced service fee available for eligible patients Vaccine supplied free to NHS for child immunisation. Page 14 of 16
Vaccination Comment PGD Payment, claim or fee available Global sum/base-line Enhanced fee FP10/ FP34D Private fee Immunisation offered under the NHS for Pneumococcal those aged 65 yrs and over or those aged Enhanced If vaccine [PPV] under 65 yrs in a clinical risk category as service fee purchased outlined in latest advice from CMO. available for FP34D to PPD eligible patients. Rabies Only recommended for individuals who may be exposed to unusual risk i.e. veterinary personnel, bat handlers etc. For pre-exposure advice should be sought from the HPA. [PDG withdrawn] administered under NHS if patient meets criteria and agreed with HPA. If vaccine purchased FP34D to PPD For post exposure vaccine can be obtained on a named patient basis from specialist HPA laboratories. For travel see Green Book. t provided under the NHS for travel. If charge levied vaccine must not be claimed on FP34D If patient requests vaccination for travel a fee should be levied for the vaccine and its administration. Smallpox indication for smallpox vaccination for any individual with the exception of some laboratory staff and specific workers at identifiable risk. Contact HPA. Tetanus [only available as combined Td/IPV] [Revaxis ] Extra cover should not be necessary if the patient is up to date with normal vaccination schedule. Booster doses are recommended every 10 yrs after primary immunisation up to a total of 5 doses. administered under NHS Tick-borne Encephalitis Available directly from the manufacturer on a named patient basis. A private fee should be levied for the vaccine and its administration. Page 15 of 16
Vaccination Vaccination PGD Payment, claim or fee available Global sum/base-line Enhanced fee FP10/ FP34D Private fee Typhoid Advised where sanitation is primitive and where the degree of exposure to infection is likely to be high. For patients in occupational risk groups contact HPA for advice. administered under NHS If vaccine purchased FP34D to PPD If charge is levied to patient, vaccine must not be claimed on FP34D. Travellers who do not meet the criteria and requests vaccination a private fee should be levied for the vaccine and administration. Varicella [chickenpox] Front line health care workers requiring vaccination [see Green Book] should be referred to employer occupational health services [see page 4]. See page 4 occupational health services. Yellow Fever Vaccination may only be administered at designated Yellow Fever Vaccination Centres. Private service via designated Yellow Fever Vaccination Centres. Page 16 of 16