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At the heart of general practice since 1960

‘Varicella vaccine for all first-time mothers’

Our experts answer your questions on immunisations and financial assistance for sick GPs

when can we charge for travel advice?

Q Can you advise if we are obliged to provide travel vaccinations? Can we charge for travel advice? There is also some confusion around the use of Revaxis and polio vaccine for travel.

A There are some travel vaccinations, given for public health reasons, namely smallpox, typhoid, cholera, polio and infectious hepatitis, for which NHS GPs are paid by the NHS. (These are the vaccines given by the doctors under the old contract with an item-of-service A or B fee.) The funding is included in the global sum of nGMS or the baseline funding in PMS.

Doctors may only refuse to give these public health immunisations if they opt out of the vaccination and immunisations additional service in which case their global sum is reduced by 2 per cent.

The personal administration system will continue under the new contract and is detailed in the statement of financial entitlements (SFE) in paragraphs 18.2 and 18.3.

Inactivated polio vaccine is no longer regarded as a childhood vaccine and patients must take an FP10 to the pharmacy for dispensing and take the vaccine to the practice for administration. The SFE excludes an administration payment for oral polio or inactivated polio and the SFE has not been changed to permit reimbursement.

Revaxis was centrally supplied and originally was only for children. Since 1 April this has changed and claims may now be submitted to the PPA for reimbursement until the situation is clarified. However, there is currently a supply problem and Revaxis cannot be supplied for adults or for travel.

Schedule 5 allows the contractor to charge a fee for treatment consisting of a travel immunisation for which no remuneration is paid by the PCT. It also allows a fee for prescribing or providing drugs, medicines or appliances (including a collection of such drugs, medicines or appliances in the form of a travel kit) which may be necessary while travelling outside the UK but which were not required when prescribed.

You may not charge for travel advice.

The new GMS contract regulations provide further information about vaccinations and immunisations. If you choose to give vaccinations and immunisation you must adhere to the regulations, schedule 2, relating to additional services.

charging patients for Hepatitis B jabs

Q Please can you clarify the issues of charging for hepatitis B immunisations?

A Hepatitis B immunisation is not routinely available free of charge.

Travel

GPs can charge patients privately for this vaccination if it is requested in connection with travel abroad. If hepatitis B immunisation is combined with hepatitis A in a single injection, you may not charge a fee for the hepatitis A component and you are, therefore, not permitted to charge for the hepatitis B element either. You may refuse to provide any travel immunisations and may refer the patient to a specialist travel clinic. Occupational health

Hepatitis B has always been a very contentious issue. Some GPs believed that occupational hepatitis B could be given by the GP acting as an ‘agent' for the employer. The GPC did not agree with this arrangement and believed it to be contrary to the regulations, as GPs were not supposed to charge the patient or anyone else on the patient's behalf for this service. It received a legal opinion that supported this view. Most LMCs are now of the view that this is correct.

You are not obliged to provide an occupational health service as part of your NHS

duties. You could be at risk of negligence if a patient did not receive appropriate accompanying advice on minimising the risk of hepatitis B and other blood borne-viruses such as hepatitis C or HIV.

You could also be at risk if the occupational hazards were not assessed with a view to reducing the risk. Hepatitis B immunisation should ideally be given only if shown to be necessary after a full COSSH assessment.

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. However, a private occupational health consultation and treatment with another doctor would probably still be the most appropriate way forward to ensure that a full preventive

occupational health service is provided.

If a GP is qualified to provide a full occupational health service it would be acceptable if the GP offered to provide an occupational health service to a company for any or all of its employees on a private basis, rather than providing individual services for specific NHS-registered patients.

The GP would therefore be offering this private occupational health service to patients registered with any practice, which could include his or her own practice.

Global sum

If hepatitis B immunisation and advice is required for some other non-occupational reason that places the patient at risk of infection, this should be provided as normal GP services which are included within the global sum. Immunisation may be required on this basis for:

• Babies born to mothers who are chronic carriers of hepatitis B virus or to mothers who have had acute hepatitis B during pregnancy

• Parenteral drug misusers

• Individuals who change sexual partners frequently

• Close family contacts of a case or carrier

• Families adopting children from countries with a high prevalence of hepatitis B

• Haemophiliacs

• Patients with chronic renal failure

• Travellers to areas of high prevalence

• Children born outside the UK and who have received a primary dose in their country of origin and who are now domiciled in the UK should have their course of the vaccine completed under GMS.

Charging for hepatitis B immunisations has been a very fuzzy area for many years and hopefully this clarifies our current understanding.

financial assistance for a gp with ill-health

Q Do you know of a source of financial assistance for GPs who require help as a result of ill-health?

A The Cameron Fund was set up for doctors who are or have been GPs, and for their dependants. It offers confidential help in times of poverty, hardship or distress. The fund aims to meet the needs of its beneficiaries in the fullest and most practical ways possible.

If you are seeking help for yourself, your family or someone you know, you should contact the fund's secretary at: The Cameron Fund, Tavistock House North,

Tavistock Square, London WC1H 9HR.

Telephone: 020 7388 0796. E-mail: secretary@cameronfund.org.uk

A preliminary telephone call to the secretary in complete confidence will establish whether the fund may be able to provide assistance and how to proceed with your application.

The Charities Trust Fund is run by the BMA and acts as an umbrella trust,

receiving donations on behalf of all doctors' charities, not just the BMA charities. This includes the Cameron Fund.

The trustees welcome donations at any time, particularly in the form of Gift Aid and bequests. They may be sent to: The Secretary, BMA Charities, BMA House, Tavistock Square, London WC1H 9JP. Tel: 020 7383 6334.

Temporary patient forms seem

to be a waste

Q Under nGMS the payment for temporary patients has been subsumed into the global sum. Is there any point filling in a temporary resident form, since there is no extra money for providing this service?

A Payment for temporary patients was included into the global sum on the basis of historic payments to general practices over the last five years. The temporary patient forms GPs fill in now will inform the current level of services provided to temporary residents and will help to determine any necessary adjustments to global sum payments in the future.

The blue book Investing in General Practice, section 2.28, sets out that where the treatment of temporary residents is insufficiently accounted for within the global sum this may be resourced either by a variation to the global sum or as a local enhanced service where, for example, a new holiday park has opened close to the practice resulting in a large influx of temporary residents.

It is therefore important to record all non-registered patients who are treated, including those requiring emergency or immediately necessary treatment.

what can we charge for a report to coroner?

Q Could you tell me what the fee is for providing a written report for the coroner?

A From June this year the BMA has sugg-ested a fee of £60.50 for a full written clin-ical report without examination, which is provided at the request of the coroner, and a fee of £30 for an extract from the medical records. The fee for a full report applies whether or not a coroner's inquest is held.

The fees are payable under section 24(2) of the Coroners Act 1988 that allows local authorities to make a schedule of fees, allowances and disbursements which may be paid by the coroner. The BMA's forensic medicine committee takes part in the annual negotiations to set these fees.

Salaried GP surprised us with sick pay demands

Q We are planning to employ a salaried GP who has asked for the BMA-recommended amount of sick leave entitlement of six months' full pay plus six months' half pay. As she will not be employed by the NHS, is she entitled to this?

A NHS regulations set out the following:

Terms and conditions

The contractor shall only offer employment to a general medical practitioner on terms and conditions which are no less favourable than those contained in the ‘Model terms and conditions of service for a salaried GP employed by a GMS practice' published by the BMA and NHS Confederation as item 1.2 of the supplementary documents to nGMS.

The model contract in the supporting documentation sets out the terms and conditions in relation to sick leave as follows:

Scale of allowances

A practitioner absent from duty owing to illness, injury or other disability shall, subject to the provisions of paragraph 48 (calculation of allowances), be entitled to receive an allowance in accordance with the NHS scale contained in paragraph 225 of the hospital conditions of service.

The practice shall have discretion to extend the application of the foregoing scale in an exceptional case. A case of a serious nature, in which a period of sick leave on full pay in excess of the period of benefit stipulated above would, by relieving anxiety, materially assist a recovery of health, shall receive special consideration by the practice.

Calculation of allowances

The rate of allowance, and the period for which it is to be paid in respect of any period of absence due to illness, shall be in accordance with paragraphs 225-244 of the hospital conditions of service.

The Agenda for Change NHS terms and conditions of service handbook sets out the following:

Scale of allowances

Employees absent owing to illness will be entitled, subject to the conditions of this agreement, to receive sick pay in accordance with the scale below (see section 12 for provisions governing reckonable service):

• During the first year of service: one month's full pay and two months' half pay

• During the second year of service: two months' full pay and two months' half pay

• During the third year of service: four months' full pay and four months' half pay

• During the fourth and fifth years: five months' full pay and five months' half pay

• After completing five years of service: six months' full pay and six months' half pay.

In the event of employment coming to an end, entitlement to sick pay ceases from the last day of employment.

Your salaried GP, therefore, would only qualify for the six months' full pay and six months' half pay after five years of service, unless of course you chose to be more supportive.

If your salaried partner stays with you for that period of time, you could be better off making her a partner at that stage.

do disability rules have an affect on practices?

Q I thought the Disability Discrimination Act only applied to large employers and did not apply to partners. Am I correct?

A When the Disability Discrimination Act 1995 first came into force it applied only to employers with more than 15 members of staff, but from 1 October last year it applied to all employers.

No practice may now discriminate against disabled employees or job applicants because of their disability, which includes making reasonable adjustments to the workplace. Since last October the law has also applied to partners in business partnerships.

The Act does not apply only to obvious and serious disabilities. It defines a disabled person as one who suffers from ‘a physical or mental impairment, which has a substantial and long-term adverse effect ºon his ability to carry out normal day-to-day activities'.

Reasonable adjustments are based upon common-sense and may vary according to practicability and affordability. Rearranging furniture to provide better access may be eminently practicable and affordable. Redesigning and rebuilding your premises would clearly be unreasonable. All employers now have a duty to consider these issues.

Allocating some duties to another member of staff or allowing more flexible hours and allowing time off for treatment or rehabilitation may be reasonable.

Employers should consider reasonable adjustments that may be required in the recruitment process.

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