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

Emporiatrics

A little history!

Emporiatrics has been the 'magazine' of the Faculty of Travel Medicine since the Autumn of 2010 when Sandra Grieve and I set it up as a general newsletter.  The publication continued to be produced every 6 months with Sandra undertaking this task as sole editor from Autumn 2013 - until she decided to step down last year.  Sufficient thanks could never be fully expressed for her dedication.  The time and toil of such work cannot be underestimated, taken on by individuals who receive no pay for such, just created with a passion for the subject and a desire to spread news and information to the travel medicine community.  To see these previous publications see here.

In financially restricted times the publication needed to change in focus and direction, so it was decided to put it into an online platform which was mobile friendly - that is the way the world is moving.

The Faculty of Travel Medicine of the Royal College of Physicians and Surgeons of Glasgow comprises healthcare professionals from a medical, nursing and pharmacy background of differing grades - from those very senior (with formal qualifications, some up to Masters level or have taken Membership exams to be admitted to Fellow, Member and Associate level giving them post nominals) to those extremely new to practice.  The FTM mission is to lead the way in helping to raise standards of practice and achieve greater uniformity in provision of services in order to protect the health of the traveller.  Bringing members in at the Affiliate level is intended to support the largest group of travel health practitioners in UK practice - support and enthuse them to hopefully take further studies and become experts themselves.

Providing support to such a diverse group is challenging, but it is hoped that those more senior would benefit from a subscription in the membership fee to Travel Medicine and Infectious Disease (TMAID) which is the official journal of the Faculty of Travel Medicine and that these individuals get involved to support the work of the FTM - and many do!

Those with an interest in travel medicine, but not trained in the subject can join the FTM as Affiliates for £30 per annum.  This entitles them to reduced subscriptions to educational events, access to the journal TMAID and Emporiatrics which is now being produced three times a year.  However it is intended that the provision of Emporiatrics is primarily orientated to this group of Affiliates - which comprise mostly nurses and pharmacists who are the main providers of travel consultations.

The electronic magazine includes the latest news of FTM activity, a travel health update, FAQs, articles on individual practitioners' passions, hints or tips.  For those who want greater academia, there is a section about TMAID.  The benefit of an online resource is that it can take a user to all sorts of resources in just a click, the variety is great with direct weblinks, videos, downloadable files and a podcast.

Emporiatrics was put together entirely by travel health professional individuals who gave of their time freely, because they felt keen to contribute to the educational arena at this more introductory level and hopefully make a difference ....... to saying nothing of giving colleagues additional support in this challenging field of practice.

If you would like to have a look at this resource click HERE and work your way though it.

Safeguarding Children and Young People

Safeguarding Children and Young People: Roles and Competencies for Healthcare Staff is a new Intercollegiate document published by the Royal College of Nursing on 30th January 2019.  This is the 4th edition replacing the 2014 publication which was previously hosted on the Royal College of Paediatrics and Child Health website.  Today, if working in Primary Care as a nurse, we have to be trained in Safeguarding to Level 3.  I found the most meaningful way of understanding and appreciating the training was in an all day face to face session although I know many undertake this online.

Click on the image below  to access.

PLEASE NOTE: Page 28 also states that the minimum level that should apply to pharmacists is level 2.  Those pharmacists undertaking professional care activities and services in care homes, urgent and emergency care settings, travel clinics, GP practice and out of hours service require level 3 competency.  

This is a substantial piece of work.  Details about Level 3: All clinical staff starts on page 27.  Education, training and learning logs are included in Appendix 4 starting on page 91 followed by a reflective log then outcomes for activities.   These tools for use would be very helpful and also enable the practitioner to form a ‘passport’ for those who move on to new jobs or other organisations.

A useful Press Release from the RCN is available here.

The Faculty of Travel Medicine with support of the Royal College of Physicians and Surgeons of Glasgow were involved the development of this document.

Importantly within this document, a reference (78) is made to the RCN Female Genital Mutilation: RCN guidance for Travel services publication which is another key guide you should be aware of.


The CQC Safeguarding children training position statement of February 2018 described 5 levels of competency and for level 3 they said:

Level 3: All clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns.

For their full documentation see here - stating for review in April 2019

So my conclusion is that all clinical staff seeing child travellers must be trained on Safeguarding to level 3 as a minimum.

Using Facebook to keep up to date!

As 2018 comes to a close I thought I'd try to post one more blog on here!  My intention to blog more didn't happen this year - mostly because I seem to be so busy and it's hard to keep all the social media going.  That's not to say I won't still try going into 2019.  My website now has over 70 pages on it and keeping that updated as well is tricky especially as it's only a hobby but one I really enjoy.  If you do notice anything not working, then please let me know via the website, I'd really appreciate it.

The place I 'post' most updates though is on my travel Facebook page.  I know not everyone is keen to get involved in FB and it does mean you need to open up an account, but you don't need to be active on there.  You can use it just to look at what is going on.  It's such a useful platform.  Just today I put a post about two Green Book chapters that have been updated....... here is an image I also posted.

The text to go with it was as follows:
Its very quiet on the travel health front right now but I noticed Chapters 1 and 10 of the Green Book were updated in December. I think these are just formatting changes. Ch.10 on 'Vaccine Damage Payment Scheme' has gone to one page with a link to the information on a gov.uk site. Ch.1 on 'Immunity and how vaccines work' seems to have had a format change only so the pages are updated to include 'December 2018' and the Chapter and page number identified at the bottom of each page. The font looks more modern as well and the green colour a slightly different shade! See https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book
While on the subject of how vaccines work, don't forget the new and helpful video posted in May this year from the Oxford Vaccine Group at https://www.ovg.ox.ac.uk/news/how-do-vaccines-work

I'm not sure just how many posts I've put on Facebook in 2018 but sometimes its 2 or 3 in a week and mostly information which will help you in your day to day practice.

So consider joining and find my page at  https://www.facebook.com/TravelHealthTraining then 'like' the page.  You can then follow my postings and will get e mail alerts when I put anything up.

Other useful ones to follow are NaTHNaC, the FCO, the WHO, the CDC etc., all easily found my doing a search.

Have fun!  And a Happy New Year to you all.