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With the flu jab season in full swing and public sensitivities heightened by the ongoing concerns over H5N1 avian influenza being passed to humans, MDU members have sought our advice on flu vaccination.

Obviously GPs are seriously concerned about the subject, which is hardly surprising in view of the amount of publicity surrounding it.

The commonest questions concern whether or not the 'worried well' should be given the vaccine, and potential problems associated with nurses running the vaccination clinics.

What about patients not in the

at-risk group?

The Department of Health recommends that people over 65 and those with chronic disease such as asthma, diabetes and chronic liver, kidney or heart disease should be offered the vaccine.

Other groups who should be prioritised include people living in care homes, frontline health care workers, people who are immunosuppressed, and, at the GP's discretion, those caring for an elderly or disabled person whose welfare may be at risk if the carer falls ill.

The department and the GMC both say the final decision on who should be offered the vaccination is a matter of clinical judgment. The GMC, in its booklet Good Medical Practice, states that the treatment doctors provide should be based on the patient's needs and the likely effectiveness of that treatment.

If you are approached by a patient who wants the vaccine but is not among the target groups you have to decide whether or not it is in the patient's interests to have the vaccine.

If you decide it is, you can offer the vaccine on the NHS.

Can I delegate to the

practice nurse?

The decision about who should administer a vaccination must be based on what is in the patient's best interests and what is legally permitted. When deciding whether to delegate the task to a nurse, GPs need to assess the competence and abilities of the nurse, bearing in mind the GMC and Nursing and Midwifery Council (NMC) advice.

The GMC says, in paragraph 46 of Good Medical Practice, when delegating to a nurse, doctor, medical student or other health care worker to provide treatment or care on your behalf: 'You must be sure that the person to whom you delegate is competent to carry out the procedure or provide the therapy involved.

'You must always pass on enough information about the patient and the treatment needed. You will still be responsible for the overall management of the patient.'

In addition the NMC code of professional conduct advises nurses that: 'You must acknowledge the limits of your professional competence and only undertake practice and accept responsibilities for those activities in which you are competent' (paragraph 6.2).'

Under the Medicines Act 1968 and later legislation which introduced patient group directions (PGDs), patients may receive a medication in general practice in accordance with a patient group direction or patient specific direction (PSD), which may include a private or NHS prescription written by the appropriate practitioner who may be a doctor or nurse prescriber.

If vaccines are to be administered under a PGD, paragraph 6 of Health Service Circular 2000/26 states that they should be administered by a 'qualified health professional', which includes nurses.

When administering a vaccination or any medication under a PGD, the doctor or nurse will be responsible for selecting

appropriate patients and for obtaining the patient's consent or, in the case of child

vaccinations, the authority of the child's parents.

The PGD, being a written document, acts as a protocol for the administration of the vaccines.

Must a doctor be on the premises when a flu clinic is in progress?

Arrangements, including training and equipment, need to be in place for the nurse to deal with any reaction that a patient may have to the vaccination, including simple faints.

A doctor should be easily accessible (for example on a mobile phone) but need not physically be in the building.

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