Saving time recording your travel consultation!

Back in the summer of 2018 I had an EMIS template built which followed the lines of my travel risk management form found at item no. 2 here.  I put it out there for some of you to trial and it generally received great feedback.  The travel consultation is complex, but sometimes writing up the information to provide evidence of all you covered and advised takes huge effort and significant time.  However in my opinion this is essential not only as best practice, but to also protect the practitioner.

The template is divided into three sections - the tabs are at the top on the left hand side as you look at the screen.  As many answers as possible have been populated into the template so that you need to write very little, but of course the beauty of EMIS is that you can simply add in extra detail if you need to.  The original template had drop down menus.

However we have a wonderful new nurse at the surgery (David Piercy) who is an absolute wizard at EMIS templates.  David has altered the format so that instead of all the information being in a drop down menu template, it's now in a list so you can read it easily and check the box of the answer that suits the best.  It possibly makes the information on the template much longer but on the other hand acts as a great prompt within your consultation.

Added to this wizardry, David has now made it SNOMED ready.  I'm told that all EMIS users will be switched to SNOMED coding so the template has had the adjustments made in readiness.  Now this last sentence is all non-sensical to me but I thought I would add it because if you've used the template in the past and it's working you may still need this new version as the other one may not!

Anyway I hope this helps.  I've put the file into a 'space' you can download it from but it will only work when you import it into your EMIS software.  I have no knowledge about  this aspect (so please don't ask me questions about it), but hopefully someone in your surgery will be able to help.  Or you could Google 'How to import a clinical template into EMIS' because leaflets will certainly come up

SO TO DOWNLOAD THE NEW TRAVEL RISK TEMPLATE 
CLICK HERE! 

and then RIGHT click on the screen and do a 'save as' 

...... all I have left to say is 

And a plea from me - I'd really appreciate you completing a short survey after using the template for evidence that the work, effort and funding put in was all worthwhile (and it would then make a really different reflective account for my revalidation!)  

The survey is HERE.

p.s. I'm not sure such templates can be built in SystmOne but if anyone out there has the skills I'm very happy to work with you from the content perspective.  Please contact me via my website.  

For the FOURTH time - Indemnity cover for the private travel vaccines - but GOOD NEWS!

Having written three time now about this in March and then May and June  (the latter two blogs I have left up for now so click on the links) this time I'm writing with good news!

This is the detail from the RCN

"In April, a new state-backed indemnity scheme for general practice (GP) staff was introduced in England. The Clinical Negligence Scheme for General Practice (CNSGP) is operated by NHS Resolution. It automatically provides cover to nursing staff working in NHS GP services. It includes self-employed workers and covers all clinical negligence claims that arise from an act (or omission to act) on the part of someone providing a GP service that is NHS-funded in England. In Wales, a similar scheme, General Medical Practice Indemnity (GMPI), was introduced at the same time. Both schemes include travel vaccinations given in GP surgeries except for where vaccinations are paid for by the patient.

The RCN is now extending its indemnity scheme to cover this gap. This means both employed and self-employed RCN members who are providing any paid-for travel vaccinations from GP practices not included in CNSGP in England and GMPI in Wales will be covered by the RCN indemnity scheme".

There was a news item on the RCN website, but this has now disappeared (update on 12.03.22) but this is a useful podcast to help you here and well worth listening to.  Details about the RCN indemnity scheme are here

I've been a member of the RCN since I qualified and am delighted about this news - the provision will be very helpful for General Practice Nurses giving the private travel vaccines going forward. 

Clinical Negligence Scheme for General Practice - a THIRD time

Having written twice now about this in March and then May (the latter blog I have left up for now so click on the link) I am astonished to be writing yet again.

NHS Resolution have now posted a FURTHER update to the document called the Scheme Scope document posted  last month that informed us the CNSGP did cover us for the private travel vaccines given in General Practice.

This new document  dated 12 JUNE 2019 now overturns that advice and it says:

• Travel vaccinations and immunisations funded by the NHS are covered under CNSGP
• Travel vaccinations and immunisations for which patients have to pay a charge are not NHS services and therefore not covered under CNSGP   
• NB. The Department of Health and Social Care (DHSC) had understood that all vaccinations and immunisations, paid for or not, were NHS services. This was based on an understanding that these services were included in the Part 4 GMS contract as an additional service and so were to be regarded as primary medical services. 
• NHS England has clarified that whilst GMS and PMS contracts allow GP practices to administer and charge for certain vaccinations, when the patient pays for the vaccine or immunisation they are considered private health services, not NHS services.  
• DHSC has taken further legal advice and considered this issue carefully. Having done so it has concluded the administration of paid for vaccinations and immunisations are not NHS services so cannot be in-scope of CNSGP. 
• These vaccinations and immunisations are covered under MDO policies.

The document is found here and directly here - see pages 7/8 in the table of information.  So it would seem that if you give private travel vaccines you do need to ensure you have additional indemnity cover from a provider such as the MDU, MPAS etc.

Whilst there is a frustration over the mixed messages we have received to date, I think the important aspect here at the present time is to ensure you are covered if you are working in General Practice and giving any private travel vaccines (and I am guessing involved in malaria chemoprophylaxis as well).  Please make sure you sort this out and share the update with colleagues.

Indemnity in General Practice AGAIN

Back in March there were a number of queries on forums  about the Clinical Negligence Scheme for General Practice (CNSGP) in relation to the private vaccines we may give in General Practice (yellow fever, rabies, meningititis ACWY for travel purposes, tick borne encephalitits and Japanese encephalitis PLUS malaria chemoprophylaxis prescriptions.

The history

From 1st April 2019 NHS Resolution started operating a new state-backed indemnity scheme for general practice in England called the Clinical Negligence Scheme for General Practice (CNSGP).

The website describes what is and isn't covered.

It appeared at the time from enquiries to different medical defence organisations that the private travel vaccines weren't covered.  HOWEVER IT SEEMS THIS TURNS OUT NOT TO BE TRUE!

NHS Resolution have now posted a document dated MAY 2019 called the Scheme Scope document or found directly here.  It's a very useful document so please read.  

It says Travel vaccinations are covered by the CNSGP as long as these vaccinations are delivered under a GMS/PMS/APMS contract or under a sub-contract for the GMS/PMS/APMS services.  In practice, most travel vaccinations will be provided by general practice under a GMS/PMS/APMS contract. The costs of some are reimbursed to the GP practice in the usual manner under the GP contract terms but the costs of some travel vaccinations may not be reimbursable under the contract. For such vaccinations, legislation permits general practice to charge patients directly. This is still an NHS charge and an NHS service so is covered by the CNSGP. 

I think the reference to link to this would be Schedule 5 of the GMS contract from 2004 where it says 'The contractor may demand or accept a fee or other remuneration' then look at section
(g) which says '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 new Scheme Scope document doesn't mention malaria chemoprophylaxis but again in the Schedule 5 as above, if you look at section (l) it says  'for prescribing or providing drugs or medicines for malaria chemoprophylaxis'.

What I would say is this has been extremely confusing but I hope this is resolved now!  I've left the rest of the original blog below for information but it's still important you check out you have insurance for your nursing activities outside your NHS care as described on the NHS Resolution website - linked above!

I am currently covered for my work in a GP practice by their group practice policy (because there are a number of GPs using it, the organisation provide additional cover for their practice nurses at no extra cost), BUT making enquiries to this company I was informed that because of the new NHS scheme and that the premiums paid by GPs will be lower, there will be a charge for nurses to be added on to an indemnity policy in the future.  I was told this was approximately £525 if working up to 24 hours a week and £695 if working up to 40 hours per week.  I understand that this will happen when your policy is due up.  

Some years ago now the RCN stopped providing indemnity to practice nurses employed by GPs.  I remained in the RCN though, not only for the professional side, but their indemnity covered me for my self employed work, and other voluntary roles - see the RCN scheme. The information on their website is very helpful about this new development - see here.   Interesting to read on there that “The RCN has heard from members and non-members alike that some GP employers have told them that  they will no longer be purchasing indemnity cover from their medical defence organisations (MDOs). As a result, the MDO will no longer provide them with support for their other legal issues like employment advice, NMC referrals, inquests and many other potential legal issues - please go to the article to read more.  

My understanding is that the principles around vicarious liability for employees remain unchanged. It is not appropriate for a GP employer to try to shift that responsibility onto their employees, so if you're employed in a GP practice you should not be required to purchase your own cover because of these changes. Your employer should take responsibility for professional indemnity cover.  You will need this in addition to the Clinical Negligence Scheme for General Practice 

MMR and travel

I did a blog on MMR and travel back in December 2017.  Measles risk continues not only now in Europe but in other parts of the world as well.  The latest measles data is published on the World Health Organization website here which also provides links to other information including the measles fact sheet.

Look at the latest information on measles from NaTHNaC on TravelHealthPro in relation to your travellers.

The Vaccination of individuals with uncertain or incomplete immunisation status flowchart published by Public Health England (most recent edition November 2017) has excellent guidance regarding your course of action if doses are missed, and one of the statements is ' Two doses of MMR should be given irrespective of history of measles, mumps or rubella infection and/or age'.

Dealing with people born before 1970 has historically caused a greater quandary, but while the Green Book acknowledges this cohort are more likely to have had all three natural infections and are less likely to be susceptible, it states MMR vaccine should be offered to those who request it or if they are considered to be at risk of high exposure (see page 219).

The December 2017 issue of Vaccine Update clarified that ImmForm stock can be used - the exact wording says Central MMR vaccine stock (ordered from Immform) can be used to catch-up anyone of any age – this also covers opportunistic catch-up prompted by travel.   Moreover, it says an item of service fee can be claimed manually via the CQRS MMR programme for each dose of MMR administered to patients aged 16 years or over. This includes patients born before 1970 who have no history of measles or MMR vaccination.  See page 5 of the Vaccine Update issue 273.

There was further excellent information on MMR in the July 2018 Vaccine Update (Issue no. 281) which asked if 'you were up to date with your MMR' on page 5. And the CQC wrote mythbuster no. 37 on Immunisation of healthcare staff which includes MMR.  The relevant information is as follows: Measles, mumps and rubella (MMR) is particularly important to avoid transmission to vulnerable groups. Evidence of satisfactory immunity to MMR is either:

• a positive antibody test to measles and rubella or
• having two doses of the MMR vaccine.

Public Health England have published new leaflets about MMR available in English, Polish, Romanian and Somali.   Order hard copy from here

Tetanus vaccine: 5 doses?

This isn't travel but because we have to also ensure patients are fully protected with the national immunisation schedule for tetanus I still think it's important.

A little history
For many years I've said once you have had 5 doses of tetanus containing vaccine then you are protected for life within the UK.  Information written in the Green Book chapter on tetanus published in 2005 and 2007 indicated that if you then sustained a tetanus prone you would require treatment which would be tetanus-specific immunoglobulin but such documents are not available online any more.

The Patient Info website on their page here states:
The primary course of three injections gives good protection for a number of years. The fourth and fifth doses (boosters) maintain protection. After the fifth dose, immunity remains for life and you do not need any further boosters (apart from some travel situations). 

We would however, administer more tetanus containing vaccine (in excess of the 5 doses) if someone was travelling to an area where there is risk and it may not be possible to secure treatment for a tetanus prone wound.  In this situation, we would continue to give a tetanus containing vaccine (Revaxis) every 10 years if needed.

New guidance
However new guidelines published by PHE on 9 November 2018 entitled Tetanus: advice for health professional  Guidance on the treatment of tetanus cases and management of tetanus prone wounds leads me to think the limit of 5 doses is not necessarily the case any longer.   The Green Book chapter 30 for tetanus was also updated on 26 November 2018 and provides a more comprehensive perspective of what is a 'tetanus prone wound'.

The table for treatment (page 11) then outlines who should receive treatment and this indicates that even those born after 1961 (when tetanus came into the national immunisation programme) with a history of accepting vaccines (which to my mind means they should have had all five doses) would still have a further dose of tetanus if they sustained a tetanus prone injury and possibly if it was more than 10 years since their last tetanus containing vaccine - but this doesn't actually seem to be stated.

I'm trying to get this verified and will post further information here when I do.  Meanwhile I've highlighted the sections of the table by adding extra comments, which lead me to think this - see below, but if you have a patient in this situation, please always check these resources thoroughly yourself.

Indemnity in General Practice

This posting has been updated because further clarification was posted in May 2019 on the NHS Resolution website.  To see the latest blog click here