Hepatitis B Immunisation
GPs are often requested to give hepatitis B immunisation covering three broad areas;
- for travel
- for occupational health
- lifestyle risk or medical conditions
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 of1 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.
- 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
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
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.
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.
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
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. Practices are only obliged to offer this service as part of good medical practice and therefore under GMS in clinically appropriate situations, which are determined on an individual basis. 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.
In short, providing hepatitis B immunisations for patients at risk is not a requirement of the GMS contract, but it is recommended that practices provide this service and request a LES if deemed appropriate.