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Focus on vaccinations and immunisations

April 2004

• Directed enhanced services
• Private income for some travel vaccines
• The global sum
• Quality & outcomes framework
• Questions & answers

Under the Red Book most vaccinations and immunisations were paid on an item-of-service basis (the main childhood immunisations were target-based). Under the new contract vaccinations and immunisations will be paid for through various mechanisms dependent on which services you as a GP wish to provide. Payment may be through the:

- global sum
- directed enhanced services
- quality and outcomes framework
- private income for some travel vaccines

The global sum
The global sum pays for essential and additional services. Regulation 15 of the Contract Regulations defines essential services. Sub-paragraph (5) provides an obligation to provide ongoing treatment and care for all registered patients and temporary residents taking account of their specific needs. This may include immunisation against disease where it is in the patient’s interest.

Within the global sum there is payment for two additional services:

Vaccinations and immunisations - all necessary vaccinations and immunisations (except the influenza and pneumococcal immunisation Directed Enhanced Service (DES), childhood vaccinations and immunisations and certain travel vaccines that can be charged for privately) as were previously set out in the Red Book. The full list of vaccinations and immunisations is attached at Appendix 1 and the Regulations at Appendix 2 .

Childhood vaccinations and immunisations – providing all necessary childhood vaccinations and immunisations as were previously set out in the Red Book. The full list is attached at Appendix 1 and the Regulations at Appendix 2 .

Should a practice for whatever reason feel unable to provide these additional services a percentage of the global sum will be extracted from the practice’s global sum or Minimum Practice Income Guarantee (MPIG) payment. For vaccinations and immunisations this will be a 2% reduction and for childhood immunisations and pre-school boosters there will be a 1% reduction.

Directed enhanced services
There are several directed enhanced services that GPs can provide in relation to vaccinations and immunisations. The influenza and pneumococcal immunisation DES is for those patients at risk of infection. For influenza vaccination this includes:
- those aged 65 or over at the end of the financial year,
- those patients suffering from chronic respiratory disease (including asthma), chronic heart disease, chronic renal disease, immuno-suppression due to disease or treatment, or diabetes mellitus,
- and those living in long-stay residential or nursing homes or other long-stay health or social care facilities.

For pneumococcal immunisation those at-risk groups include:
- those aged 75 or over at the end of the financial year or
- from 1st April 2005, those aged 65 or over at the end of the financial year.

Both are annual campaigns, the influenza scheme is time specific whilst pneumococcal can be given throughout the year. Practices do not have preferred provider status for this DES.

Practices providing the childhood vaccination and immunisation additional service have preferred provider status for the childhood immunisation DES which incorporates the 70% and 90% target payments that existed under the Red Book. Should practices have particular difficulty in meeting these targets they need not apply to be commissioned for this DES and consider whether they wish to opt out of giving the vaccinations through the additional service.

Quality and outcomes framework
Whether a practice is commissioned for the flu and pneumococcal DES or not there are points to be gained in the Quality and outcomes (Q&O) framework for vaccinating patients within specific disease groups. The following indicators all reward doctors for vaccinating patients against flu – COPD8, DM18, ASTHMA7, STROKE10, CHD12. The flu DES has a 70% target (although an item per vaccination will be provided whether the target is met or not) and the Q&O indicator target can go as high as 85%. Any practice that does the flu DES successfully will also automatically qualify for quality points. If a practice does not take on the flu DES but still vaccinates patients in disease groups they can earn quality points.

Private income for some travel vaccines
The situation with regard to travel vaccines and what can and cannot be charged for has not altered from the old to the new General Medical Service (GMS) contract. Under the Red Book a limited number of travel vaccines (see Appendix 1 for the list ) were provided on the NHS. This was for public health reasons. The public health agenda has not altered with the new contract and therefore those travel vaccines that were provided by practices on the NHS before the 31st March shall continue to be provided by them from 1st April. The only exception shall be for those practices that opt-out of the additional vaccinations and immunisations service and they will have their global sum abated by 2%. Practices opting out of the additional service will not be able to charge their registered patients for travel vaccines which are available on the NHS.

Schedule 5 of the new contract replaces paragraph 38 and lists all those services which practices are able to provide privately. This includes all travel vaccines that are not provided through the NHS for public health reasons (please see Appendix 3 for Schedule 5 ).

Questions and Answers
There was talk of a stock order system in England and Wales replacing the personal administration payments – will this still happen?
The GPC has been in further discussion with the Department of Health and NHS Confederation on this issue. For the present time it is not envisaged that the personal administration system shall cease, but rather it is likely it will be refined to best meet the needs of modern clinical practice.

Why does the new contract still contain the 70% and 90% childhood immunisation targets which GPs find so iniquitous?
The GPC made every effort to negotiate exception reporting into the childhood immunisation targets, as a way of ensuring GPs were not financially penalised because parents made a conscious choice not to vaccinate their children. The Department of Health considers GP involvement in childhood immunisation imperative and would not agree to this amendment. As a result the targets were detached from essential and additional services and put into a directed enhanced service. In this way, doctors who have particular difficulty in achieving the targets need not take on this service.