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Focus on travel immunisation

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This guidance is to help GPs and Local  Medical Committees (LMCs) understand the regulations in relation to travel immunisations as they currently  stand. Clinical information on travel is contained in the ‘Green Book’ and on the NaTHNaC website.

The regulations regarding the NHS provision of immunisations for travel can be traced back to the original  ‘Red Book’ regulations of the 1960’s. They were written to cover the immunisations available at that time and consequently do not reflect today’s clinical practice, and have never been fully updated. In 2004 the new GMS contract 1took those regulations and carried them into the new contract as an additional service.

Consequently everything in the Red Book was transferred unchanged and included in the global sum of payments rather than the previous item of service system.

The change in availability of immunisations and the nature of foreign travel has made these old regulations ever more difficult to interpret, with understandable confusion over how they apply to current practice. This has now become clearer with the publication of Annex BA of the SFE2. An example is hepatitis A (referred to by its old name of “Infectious Hepatitis” in the Red Book). This was previously paid under item of service for one dose as that was all that was available before the active vaccine was introduced in 1993. Although it was always intended to cover courses of treatment this was not clear in the Red Book, and the new regulations now clearly states that “a course of immunisation should be offered”.

 

Principles

Most misunderstandings of the regulations are due to the confusion between the clinical advice for when to administer an immunisation for travel (as set out in the Green Book see note 3) and the regulations indicating how practices are paid for it (as set out in the former Red Book).

  • The Green Book advises what to give and when
  • The Red Book advised what services were funded by the NHS

If an immunisation is in the Green Book but not the Red, the assumption is that a fee could be charged to the patient. The present confusion arises because only the Green Book has been regularly updated.

There are three categories of travel immunisations:

  • Those that must always be given as part of NHS provision through GMS Additional Services (see Annex BA of the SFE2 see note 2)
  • Those that cannot be given as an NHS service
  • Those that can be given as either NHS or as a private service

 

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 GMS (see note 4) 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)5
  • Combined hepatitis A and B – all doses
  • Typhoid* - first and any booster doses (see note 6)
  • 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 (see note 6)

The full list of list of travel immunisations available on the NHS is listed in Appendix 1 (based on Annex BA of the Statement of Financial Entitlements published 30 April 2012 2).

 

Travel immunisations that cannot be given as an NHS service

The following immunisations are not remunerated by the NHS as part of additional services:

  • Yellow Fever
  • 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.

 

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 regulations7 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. 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. 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
  • no charge can be made for simply recording immunisation details for the patient’s personal record

To provide this as a private service
The practice may 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.

  • the practice may charge for the administration of the vaccine.

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).

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).

 

Clinical travel advice

Green Book (Immunisation against infectious disease)

The National Travel Health Network and Centre (NaTHNaC) provides health information for health professionals and travellers

 

Further reading

Red Book (Statement of fees and allowances payable to general medical practitioners in England and Wales) is unavailable online.
Equality Act 2010 (formerly known as the Disability Discrimination Act)
For more in-depth information about providing hepatitis B immunisation for travel, occupational health and medical reasons please see our Focus on hepatitis B immunisations.

 

Notes:

  1. General medical services legislation (23 March 2010)
  2. Statement of financial entitlements (Amendment no.2), directions 2012, NHS England (PDF 1.24M)
  3. Immunisation, the Green Book 
    Latest information on vaccines and vaccination procedures for all the vaccine preventable infectious diseases that may occur in the UK.
  4. GMS Regulations (Schedule 2, paragraph 4 and Schedule 5, paragraph 1 (g)) - (parallel arrangements for PMS/APMS and in devolved nations).* Note that the oral typhoid vaccine is classed as personally administered and although it is not a vaccine in the conventional sense, it is listed as an Oral Vaccine and as a High Volume Vaccine on the NHS Prescribing Services system and can therefore be claimed on the FP34 appendix. It is also accepted for practices to print it on an FP10 and submit it with the end of month submissions.
  5. For persons travelling to areas, as defined by NaTHNaC, where the degree of exposure to infections is believed to be ‘high’.
  6. For persons travelling to an area, as defined by NaTHNaC, where they may risk exposure to infection as a consequence of being in that area; or to a country where it is a condition of entry to that country that persons have been immunised. Note that the SFE only refers to poliomyelitis, whereas the vaccine is only available in the combined Td/IPV vaccine
  7. The National Health Service (General Medical Services Contracts) Regulations 2004
  8. National Travel Health Network and Centre (NaTHNaC)
  9. The NaTHNaC website only refers to risk which is assumed be ‘significant’. The definition in the regulations is ‘high’, as ‘significant’ does not have any meaning in law and cannot be in the regulations. Since the risk can never be zero the wording in the regulations has to remain ‘high’.
  10. The regulations use the words ‘whichever clinically appropriate’ to ensure that immunisation schedules for patients are completed, with primary and booster immunisations.

 

Appendix 1

Vaccines and immunisations for persons travelling abroad
Contractors who offer and provide immunisations for travel must have regard to the guidance set out in the ‘Green Book’3 and the information provided by NaTHNaC8.

Cholera
A course of immunisation should be offered to persons travelling
(a) to an area, as defined by NaTHNaC, where they may risk exposure to infections as a consequence of being in that area or
(b) to a country where it is a condition of entry to that country that persons have been immunised.
The appropriate course of immunisation is dependent on age and will consist of an initial course and a subsequent reinforcing course of immunisation. If more than two years have elapsed since the last course of immunisation, a new course of immunisation should be commenced.

Hepatitis A
A course of immunisation should be offered to persons travelling to areas, as defined by NaTHNaC, where the degree of exposure to infections is believed to be ‘high’9.
Persons who may be at a higher risk of infection include those who
(a) intend to reside in an area for at least three months and may be exposed to hepatitis A during that period; or
(a) if exposed to hepatitis A, may be less resistant to infection because of a pre-existing disease or condition or who are at risk of developing medical complications from exposure.

The number of doses (either two or three) of the vaccine required is dependent upon the chosen vaccine and should be sufficient to provide satisfactory long-term protection against the disease.

Poliomyelitis
a) A course of immunisation (using an age appropriate combined vaccine) should be offered to persons travelling
(i) to an area, as defined by NaTHNaC, where they may risk exposure to infection as a consequence of being in that area; or
(ii) to a country where it is a condition of entry to that country that persons have been immunised.

(b) Children under the age of 6 years are to be offered immunisation in accordance with the Childhood Immunisations Scheme (Section 8)3.

(c) Persons aged 6 years and over who have not had the full course of immunisation or whose immunisation history is incomplete or unknown are to be offered, either
(i) a primary course of three doses plus two reinforcing doses at suitable time intervals; or
(ii) as many doses as required to ensure that a full five dose schedule has been administered, which ever is clinically appropriate(see note 10).

Typhoid
A course of typhoid vaccine should be offered to persons travelling:
(a) to an area, as defined by NaTHNaC, where they may risk exposure to infection as a consequence of being in that area; or
(b) to a country where it is a condition of entry to that country that persons have been immunised.
The number of doses (including reinforcing doses) required is dependent on the chosen vaccine and is to be offered so as to provide satisfactory protection against the disease.

 

Downloads

Focus on travel immunisations - guidance for GPs (November 2012) (PDF 56.3K)