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While I welcome the attempt to clarify the issues regarding charging for hepatitis B immunisations (Features, July 23), I feel they are still as fuzzy as ever.

Dr Dewbury states initially that GPs can charge patients for hep B immunisation 'when requested for travel abroad'. This I agree with as travel vaccines were 'mapped across' from the Red Book to GMS2. But she then goes on to say 'if hepatitis B immunisation is required for some other non-occupational health reason.....it should be provided as normal GP services which are included in the global sum' and indications for this include 'travellers to areas of high hepatitis prevalence'.

Surely the two statements are contradictory. What is the correct interpretation?

Additionally, while I agree that 'practices may refuse to provide any travel vaccines' it should be pointed out that if they were doing them (eg hepatitis A and typhoid) prior to March 31, 2004, and then ceased they should lose

2 per cent of their global sum or around £2,000 per GP.

Another area of hep B immunisation that needs a clear statement from the Department of Health is that regarding the emergency services.

Many police no longer have access to occupational health services, but it doesn't require a degree in occupational health to realise they are at risk. Are we really going to charge the police (or ambulance and fire crews) that come through our doors for hepatitis B vaccine?

And, if we can't, is referring them to a neighbouring GP who can, really morally acceptable? Surely we should just give the vaccine and accept the profit we get from the PPA.

Dr SF Riley

Manchester

Dr Christine Dewbury replies:

GPs are generally permitted to charge for routine travel immunisations. But if the travel is to an area of high prevalence, where the risk of acquiring the infection is very high, with a consequent high public health risk on return, then this should be given as GMS.

For example, a traveller to Spain where the prevalence of hepatitis is not high, and who is therefore not in the defined high-risk group covered by GMS, may request hepatitis immunisation for a camping holiday. This would generally be a private arrangement with the GP.

A patient travelling to Bangladesh to work in a flood relief project would be at high risk and this is covered by GMS regulations and the patient may not be charged.

Dr Riley is correct that if practices opt out of travel immunisations that were previously provided under GMS (not privately) then they would forfeit part of their global sum (2 per cent) as set out in the Blue Book Investing in General Practice.

I added in the feature: 'If the patient is at very obvious risk, and has no access to an occupational health service, it could perhaps be argued that it should be part of normal NHS primary care to provide protection from a potentially very serious, or even fatal, infection.'

In the situation where a patient is at obvious occupational risk and has no access to occupational health services, then a GP is not permitted to charge a registered patient privately. There could well be a GMS obligation to immunise and there is also probably a common law and ethical requirement to act in the patient's best interests.

But this raises the whole question of whether this is in the best interests of the patient because of the wider issue of the other aspects of an occupational health service that must be addressed to protect the patient adequately from the occupational risk of other blood-borne viruses. This is why in the feature I suggested a full occupational health service is always preferable.

The employer also has a legal duty of care to the employee and has an obligation to provide an occupational health service if workers are to be protected effectively and are not to receive the false reassurance of hepatitis B immunisation that could put them at risk of other blood-borne diseases if there is no risk management strategy, training, follow-up, etc.

Public services should not be allowed to evade their legal duty of care to their employees, which is what they are able to do if GPs give hepatitis immunisations to their employees on an ad hoc basis.

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