General practitioner Practice manager GP practices

Last updated:

Focus on hepatitis B immunisations

Created:

Introduction

The clinical benefits of hepatitis B immunisation are clear, but there is less clarity in the understanding of the regulations covering hepatitis B immunisation.

This is manifested by some practices being pressurised by their Primary Care Organisations (PCOs) into giving hepatitis B immunisation for travel solely as a private service, and by some practices charging for occupational hepatitis B.

GPs are often requested to give hepatitis B immunisation covering three broad areas:

  • For travel
  • For occupational health
  • For medical reasons (e.g. IV drug use for renal disease).

This paper aims to deal with the breadth of hepatitis B immunisation; to clarify the circumstances where charges can be made and where active attempts to encourage immunisation ought to be made.

 

Travel

Hepatitis B immunisation for travel is not remunerated by the NHS as part of additional services. However, the regulations do not impose any circumstances or conditions as to when hepatitis B immunisations should be given on the NHS or as a private service. This causes confusion and the ambiguity stems from the regulations regarding the charging of patients that are registered with the practice. Schedule 5 of The National Health Service (General Medical Services Contracts) Regulations 2004 of states that:

"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, rather than the PCO or commissioning group. Technically the practice may charge any patient a private fee for hepatitis B for travel, as long as it is not combined with hepatitis A, which must be given on the NHS.

Ultimately it is up to the practice to decide when and if it is clinically appropriate to use the combined immunisation, such as where there is high risk of infection or a barrier to compliance. 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. For further information how to provide this service, please see Focus on travel immunisations

Some confusion may also be caused by the advice given in the ‘Green Book’ (Immunisation against infectious disease) and the former ‘Red Book’ (Statement of fees and allowances payable to general medical practitioners in England and Wales)(The Red Book is not available to download electronically).

In the Green Book, hepatitis B for travel is indicated for:

“People travelling to or going to reside in areas of high or intermediate prevalence…who place themselves at risk when abroad…..include sexual activity, injecting drug use, undertaking relief aid work and/or participating in contact sports…. Individuals at high risk of requiring medical or dental procedures in such countries should therefore be immunised”. (Full text in appendix 1)

Giving hepatitis B immunisation to patients who are travelling but where it is not indicated in the Green Book is inappropriate and wasteful of resources, however funded.

According to the 'Red Book' (paragraph 44.5), 'vaccines [including hepatitis B]..which are supplied and personally administered under the arrangements in Regulation 19(b) a practitioner may claim payment whether or not he or she is a dispensing practitioner.'

 

Summary

  • As a practice you may choose whether to give single hepatitis B immunisation for travel on the NHS or privately. Combined hepatitis A and B immunisations must always be given on the NHS.
  • The GMS regulations (2004) state that practices may charge for hepatitis B immunisations.
  • The Green Book advises what to give and when.
  • The former 'Red Book' advised what services were funded by the NHS.

Please refer to Focus on travel immunisations for further information.

 

Occupational health

This section replaces and updates the former guidance Hepatitis B vaccination for employees at risk (2005).

It is GPC's view that there is no obligation under the GMS regulations for a practice to provide occupational health services for patients. That responsibility rests with the employer under Health and Safety Legislation, and in occupations where there is a risk to health from any form of work related infection it is the employer’s duty to assess that risk and, if present, to protect the workforce. Examples of the groups that are considered at occupational health risk and require hepatitis B immunisation is set out in Chapter 18 of the Green Book (see extract in Appendix 2).

The same applies for healthcare students who often request a hepatitis B immunisation prior to, or on entering, a course. Medical Schools are legally responsible for providing a full occupational health service to their students and applicants. This should include appropriate training for example in risk reduction and coping with needle stick injuries. By providing a hepatitis B immunisation, a GP could place inexperienced healthcare students at risk by providing a false sense of security and potentially exposing them to clinical risk of other blood borne infections, including HIV and hepatitis C, before they have received appropriate training.

Model letters (available to download from this page), which can be provided to patients who request a hepatitis B immunisation for occupational health purposes, or to the employers, are available in Appendix 3.

It is worth noting that a practice can choose to enter into a private contract with an employer or medical school to provide this service, either to a group of employees or for a single employee. The practice would need to carefully consider the nature of the service required for the employees e.g. whether a full occupational health assessment would be necessary. This will include necessary blood tests (see question 11 of the FAQs at the end of this document).

If a practice decides to enter into a contract to provide such a service, it cannot accept a fee from the registered patients, only from the employer. This is because the exceptions to the ban on charging for GMS set out in Schedule 5 Regulation 24 of the GMS regulations, says:

1. The contractor may demand or accept a fee or other remuneration -

(b) 'from any body, employer or school for a routine medical examination of persons for whose welfare the body, employer or school is responsible, or an examination of such persons for the purpose of advising the body, employer or school of any administrative action they might take.'

Based on this legislation, a practice could enter into a contract with an employer for the provision of the hepatitis B immunisation, even if it resulted in treating patients registered with the practice.

One area of difficulty for practices is where there seems to be an occupational health risk but where there is no employer to assess and manage this. An example is in the case of a care worker or health worker who is self employed and works through agencies. Practices may wish to refer such patients to other practices where they can be offered this occupational care as a private service (as the self employed are their own employer and any costs are a legitimate business expense). An alternative is that the practice decides to provide the immunisation as an NHS service for free and claim reimbursement of the vaccine costs. Both routes are acceptable and will depend on the volumes involved and the practice’s own agreed policy. Note that practices cannot under any circumstances charge their NHS patients for the occupational service or the hepatitis B vaccine provision.

 

Lifestyle risk or medical conditions (or 'patients at risk')

Patients whose lifestyle or medical conditions put them at risk of hepatitis B infection, including family members of those who have already contracted hepatitis B, also need immunisation.

Certain lifestyles will put some people at more risk of infection and practices can only act upon patients giving the information. Examples of this may include tattoo parlour workers (difficulty arises from self-employed tattoo parlour owner versus occupational health aspects of employee working), or family members of intravenous drug users and prostitutes.

The judgement as to whether these are lifestyle risks or occupational risks (in the case of the tattoo shop owner or prostitute) is relevant to a strict interpretation of GMS obligations. However, practices are, once again reminded of the primacy of care for the patient and Good Medical Practice.

Giving hepatitis B for those at lifestyle or medical risk is not part of the additional service component of the global sum and commissioners should ensure that proper arrangements are in place for this service to be provided, either within practices or elsewhere. However, case-finding and call and recall would be more of a public health issue, and might be better served by a LES. The GPC would encourage PCOs and Clinical Commissioning Groups to develop such LESs.

 

Hepatitis B for new born babies at risk – new vaccination programme since April 2014

New born babies whose mother has Hepatitis B are at increased risk of contracting the disease. This programme is intended to identify these new born babies and ensure they receive vaccination (first three doses) within the first three months after birth and fourth dose at the age of 1. This vaccination is incorporated into SFE for providers of the childhood immunisation additional services.

 

Hepatitis B immunisations – Q&A

         Hepatitis B immunisation for travel

  1. Can I give hepatitis B immunisation for travel on the NHS?

    Yes. The GMS regulations do not prohibit NHS provision and it can be given on the NHS in certain circumstances and the individual practice can decide how to give their patients hepatitis B immunisation using their clinical judgement. However, it is common practice to give this immunisation privately (for further information see Focus on travel immunisations).

  2. Can I charge for giving hepatitis B immunisation for travel?

    Yes. NHS Regulations (Schedule 5 regulation 24) specifically exempt the giving of immunisations for travel from the ‘ban’ on charging patients on your registered list for medical services. This ability to charge is limited to immunisations where there is no reimbursement available from the PCO.

    As single hepatitis B immunisations do not attract such remuneration you may charge the patient, as long as it is not combined with hepatitis A, which must be given on the NHS.

  3. Can I charge for a private immunisation despite the Green Book recommending hepatitis B immunisation?

    This is an area that is often misunderstood because the Green Book advises what immunisation to give, whereas the former “Red Book” advised what services were funded by the NHS.

    Any single hepatitis B immunisation for travel can be given privately (but not in combined vaccine). If there is a lifestyle issue then this is dealt separately in the section below; however if the immunisation is given for travel alone then the practice may charge - whatever the Green Book may say.

  4. Can I charge when hepatitis B is in a combination immunisation?

    If the other immunisation in that combination is reimbursed then you cannot charge the patient and it has to be given on the NHS. As the only commercially available combination for hepatitis B is with hepatitis A then this immunisation must be given on the NHS.

  5. What if there is a lifestyle and travel issue?

    If there is a lifestyle risk then you cannot charge. For example, a man who has sex with another man should receive hepatitis B protection as a lifestyle issue. The fact that the patient has, for example, presented at the travel clinic due to their trip to a Gay Pride festival overseas does not negate the fact that they have a lifestyle indication and so must receive the immunisation as an NHS service. You cannot charge a private fee.

  6. Can I use a combination immunisation to avoid having to charge the patient?

    If a travel risk assessment highlights that both of these immunisations are required, then the practice may decide that the benefits of fewer injections and increased compliance may make this a sensible alternative.

    However, it is unacceptable to subjugate responsible clinical behaviour in order to use an inappropriate combination just because that combination has to be given as an NHS service. Patients who have had hepatitis A immunisation in the past should never be given the combined immunisation just because they will not have to pay. After all, charging the patient should not be a barrier to acceptability, as the monovalent hepatitis B can be given on the NHS too (see above).

    Hepatitis B immunisation for occupational health

  7. Whose responsibility is it to provide hepatitis B immunisation for occupational health?

    If the patient is employed then it is the duty of their employer to do a COSSH5 risk assessment for hepatitis B. If that risk assessment indicates that the employee is at risk then the employer is responsible for arranging immunisation. This might be with their own occupational health service (particularly appropriate for NHS staff) or with a contracted private provider of occupational health services. If a patient is self employed then the responsibility lies with the patient.

  8. Is the practice obliged to give hepatitis B immunisation for occupational health?

    No. There is no obligation and the patient should be advised that it is the responsibility of their employer to organise hepatitis B immunisation. The employer or medical school can enter into a private contract with the practice to provide this service if they choose, or make alternative arrangements. Registered patients who are self-employed may be referred to an alternate provider as there is no NHS provision or funding.

  9. Can the practice charge for hepatitis B immunisation for occupational health?

    No. There is no obligation and the patient should be advised that it is the responsibility of their employer to organise hepatitis B immunisation. The employer or medical school can enter into a private contract with the practice to provide this service if they choose, or make alternative arrangements. Registered patients who are self-employed may be referred to an alternate provider as there is no NHS provision or funding.

  10. Can the practice charge the employer?

    If the patient’s employer states that their risk assessment indicates that their employee (your patient) is at risk of hepatitis B and requests that the practice contracts with them to provide such an immunisation, then the practice can choose to do so. Practices can have agreements, for example with police colleges, where they provide hepatitis B immunisations ONLY at the request of the employer. It must be clear that this is an arrangement between the practice and the employer and that the patient is not being charged.

  11. Should the practice provide a service for NHS staff?

    The practice is not obliged to do so. In many areas there has been local negotiation between LMCs and PCOs and this has resulted in Locally Enhanced Services (LESs) for the provision, administration and associated testing hepatitis B immunisation of NHS staff and students for occupational health reasons. This solution is advantageous for practice, patients and the PCO.

    Hepatitis B immunisation for medical and lifestyle reasons

  12. Can I provide hepatitis B immunisation for medical or lifestyle reasons on the NHS?

    Giving hepatitis B for those at lifestyle or medical risk is not part of the additional service component of the global sum, and commissioners should ensure that proper arrangements are in place for this service to be provided, either within practices or elsewhere.

  13. Who should receive hepatitis B immunisation?

    The Green Book6 details those who should receive hepatitis B immunisations (see Appendix 1). Practices should be alert for patients at risk (which may include family members) and ensure that immunisation is advised for this group.

  14. Can the practice earn money from this provision?

    Practices in England and Wales can give the immunisation from stock and claim reimbursement.

 

Further Reading

Green Book (Immunisation against infectious disease)

"Red Book" (Statement of fees and allowances payable to general medical practitioners in England and Wales) is unavailable online.

Focus on travel immunisations

Focus on vaccines and immunisations

 

Download

Focus on hepatitis B immunisations - guidance for GPs (August 2012) (PDF 76.6K)

Model Letter - Patients who request Hep B immunisation for occupational health reasons (Word 10.7K)

Model Letter - Employers whose employees request Hep B immunisation for occupational health reasons (Word 11.3K)