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Wednesday 28 September 2016
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Running a specialised GP travel health clinic

Patient & Services

JOYCE SKEET
RGN, MFTM MSc Travel Medicine (Glasgow)

Practice Nurse
Holbrook Surgery, Horsham, West Sussex

Joyce trained as a nurse at the Adelaide Hospital in Dublin. She now works as a practice nurse in Holbrook Surgery, Horsham, specialising in travel medicine and diabetes. Joyce regularly lectures and has had a number of articles on travel medicine published. She enjoys walking and travelling – outside Europe, she has visited South East Asia, South Africa, Sri Lanka, the Middle East, Cuba and, most recently, China

Most people enjoy travelling and the World Tourism Organization forecast that by the year 2020 international worldwide arrivals are expected to reach nearly 1.6 billion, with as many as 1.2 billion intra­regional and 378 million long-haul travellers.(1) The forecasted arrivals by region will be Europe (717 million tourists), East Asia and the Pacific (397 million) and the Americas (282 million), followed by Africa, the Middle East and South Asia. But it is worth noting that the growth in international tourists' arrivals has slowed recently due to the credit crunch and oil price rises.(1)

The Office for National Statistics shows that British residents alone made 65.2 million visits abroad in 2008, with an increasing number to Africa, Asia and Latin America.(2) Travellers include tourists, businessmen and women, diplomats, journalists, students, technical troubleshooters, aid workers, pilgrims, immigrants, refugees, military personnel, sporting participants, spectators and many others.

One of the world's fastest-growing industries is tourism, and in 2007 international tourism generated US $856bn (€625bn).(3) This was due to the increase of cheap air travel, accommodation and package tours. With this rapid growth and the speed of travel, many people can be back in their homes before the signs of illness present.

Travel medicine has evolved out of a need to keep the traveller safe and healthy without destroying the joy of travel. In general practice it is important to have a current evaluation of the service and who exactly is providing this service. In the past, the traveller would have seen their GP, with the main focus on immunisations. Due to the number of travellers going abroad today and the increased awareness of the general public to travel-related illness and disease, primary healthcare teams are now providing comprehensive pre-travel advice as well as immunisations to their patients.

Health promotion has been part of the daily work of the primary care team for many years, and research has indicated that pre-travel clinics could significantly reduce morbidity and illness in travellers.(4) Primary care travel clinics can provide a comprehensive service, which is not only beneficial to the patient and his family, but also generates income for the practice.

In recent years there has been an increased interest in providing this service, and many GPs and practice nurses have embarked on training programmes for travel medicine to give them the specific knowledge and qualifications to meet this demand. One of the principal objectives of the health professional is to ensure that the traveller is well informed about the health risks and diseases that could occur during their stay abroad.

The public can get their pre-travel health advice and information from many different sources, but its reliability is questionable. Many are advised by their travel agent when booking their holiday to visit their GP or practice nurse; some go to a dedicated travel clinic and now, with the internet, many check online.

Most travellers are seen "ad hoc" by their GP or practice nurse, but some surgeries are registered as a Yellow Fever centre and run a dedicated travel clinic for their patients. GPs and practice nurses trained in travel medicine can spend considerable time giving pre-travel advice and administering vaccines to travellers.

This time costs money, with additional costs spent advising travellers on the telephone, making appointments, stocktaking, ordering and claiming for the vaccines. While some of the costs of providing a travel health service are readily identifiable, such as the purchase cost of vaccines, other operating costs are not so transparent.

Developing a travel clinic may be seen as the way forward, and it is possible that in the future primary care trusts (PCTs) may require a service that delivers a measurable standard of care, therefore a number of questions need to be asked before setting up a dedicated travel clinic:

  • Does the practice see enough patients travelling to justify the expense of setting up a travel clinic? An audit of travellers seen in the last 3–6 months could be a starting point.
  • Does the practice have a nurse or doctor who is trained, or is interested in being trained, to deliver a professional pre-travel and immunisation service to the practice population?
  • Has an estimate of the cost of running a clinic been calculated? This should include: staff costs; the cost of occupying and running the clinic/treatment room; equipment and office supplies required; professional business services and charges.
  • Has the practice access to a dedicated internet travel advice service, eg TRAVAX (see Resources)? Many PCTs already subscribe to this service, so the travel nurse or doctor can log on for up-to-date information on destinations, malaria areas, prophylaxis, advice sheets and immunisations.

Practical aspects to be considered before starting a travel clinic
Is there a room available to run a travel clinic? Does the room have a specialist vaccine fridge with capacity to accommodate a range of travel vaccines? Does it have a couch and resuscitation equipment readily available? Would more nurse hours be required to run this service?

Sources of travel vaccines and purchasing details
There are two main vaccine manufacturers that supply drugs for travel medicine in the UK. These are Aventis Pasteur MSD and Smithkline Beecham (SKB), and discounts apply for bulk purchase. Vaccines ordered are usually delivered the next day and it is important that the "cold chain" is not broken, with the temperature of the vaccine fridge between 2ºC and 8ºC and recorded daily. A dedicated electricity supply for the fridge is essential, as the replacement cost of the vaccines could be considerable in the event of it being turned off.

Sources of income from travel medicine
To understand the complex way general practices can generate income from travel medicine, it is necessary to consider the following:

  • Reimbursement of vaccines from the Prescription Pricing Authority (PPA).
  • Charges for "private" vaccines.
  • Non-NHS fees for travel abroad.
  • Private prescriptions for travel abroad.
  • Yellow Fever clinics.
  • Selling travel goods and medical kits.

Income from the PPA
GPs in England and Wales are entitled to claim a fee from the PPA for purchasing and dispensing certain travel vaccines to NHS patients registered with the practice. This claim or reimbursement is based on a formula set down by the PPA. This is calculated in the following way:

Basic cost of a vaccine (listed in the British National Formulary (BNF), Mims or drug tariff) minus a percentage discount + VAT allowance + a dispensing fee. (The percentage discount scale is set down in GMS Statement of Financial Entitlement (SFE) 2005).(5)

At the end of each month, the number of vaccines used is counted. Instead of generating a prescription for each one, they are claimed as a bulk entry using Form FP 34PD (Appendix). This form must be submitted to the PPA by the fifth day of the following month. Payments follow three months in arrears.

The following vaccines can be claimed in this way:

  • Hepatitis A (adult and paediatric).
  • Typhoid.
  • Tetanus, diphtheria, polio.
  • Combined hepatitis A and B
  • (adult and paediatric).
  • Combined hepatitis A and typhoid.

Travellers can also be given a prescription for vaccines, in which case they then have to go to a pharmacy to order and collect the vaccine, and then make an appointment for its administration. Many practices do not administer vaccines in this way, as there is no guarantee that the vaccine has been kept at the correct temperature and the "cold chain" has not been broken.

Charges for "private "vaccines
Direct payments from non-NHS (private) patients or from NHS patients who are travelling abroad to areas where certain immunisations are recommended can be made for the
following vaccines:

  • Hepatitis B.
  • Influenza.
  • Japanese encephalitis.
  • Meningitis ACWY vaccine.
  • Oral typhoid.
  • Pneumococcal vaccine.
  • Rabies.
  • Tickborne encephalitis.
  • Yellow Fever.

If a GP charges an NHS patient for a vaccine, they are not allowed to make a claim for that vaccine from the PPA. To do so could be found in breach of their Terms of Service.

Childhood vaccines are available and can be ordered from the vaccine supply website immForm (see Resources), part of the Department of Health. Childhood vaccines are excluded from reimbursement payments from the PPA. Payments for meeting targets are paid in the Global Sum.

Non-NHS fees for travel abroad
Fees can be charged by GPs for non-NHS services to travellers for travel abroad. These fees are at the discretion of the practice, usually decided on by a "pool" of local charges. There are no set guidelines on how much a practice can charge for a particular vaccine, but it is advisable for practices to ensure a list of charges are clearly displayed in the reception area – see Table 1.

[[JS_Tab 1]]

Private prescriptions for travel abroad
Private prescriptions can be issued to travellers for the following items:

  • Continuing treatment (longer than three months).
  • Malaria prophylaxis.
  • Medicines for use outside the UK, ie, antibiotics.

In February 1995, the Department of Health issued regulations permitting GPs to charge for prescribing or providing antimalaria drugs.(6) Antimalaria drugs for prophylaxis include:

  • Doxycycline.
  • Larium® (Mefloquine).
  • Malarone™ (Atovaquone and Proguanil).

Becoming a Yellow Fever clinic
The practice could become a Yellow Fever centre so that travellers registered with other practices can be offered a Yellow Fever vaccine if required for their destination. Details on how to become a Yellow Fever centre and training are available on the National Travel Health Network and Centre (NaTHNac) website (see Resources).

Medical kits and travel goods
These items can be purchased in bulk to sell to travellers, and a list with prices can be displayed in the clinic.

Benefits of running a dedicated travel health clinic

  • Healthcare professional can concentrate on one topic and deliver an accurate and focused service for the traveller.
  • Travellers have a consultation with a travel health specialist.
  • Opportunity to update records as these "well" patients who do not attend the surgery regularly.
  • Generates substantial income for the practice by offering a comprehensive pre-travel health consultation with income from private vaccines and private prescriptions, and possible sale of travel goods.
  • Travellers registered at other practices may be attracted by the service offered.
  • Job satisfaction for the healthcare professional running the clinic.

Resources
ImmForm
www.immform.dh.gov.uk

National Travel Health Network and Centre (NaTHNac)
www.nathnac.org/pro/yf_procedure.htm

Travax – advice for healthcare professionals
www.travax.nhs.uk

References
1. World Tourism Organization. Tourism 2020 Vision [homepage on the internet]. Available from: http://www.unwto.org/facts/eng/vision.htm
2. Office for National Statistics. MQ6 Transport Travel and Tourism: overseas travel and tourism. London: ONS; 2009. Available from: http://www.statistics.gov.uk/downloads/theme_transport/mq6-q4-2008.pdf
3. Office of Travel and Tourism Industries (OTTI). World & US International Visitor Arrivals & Receipts [homepage on the internet]. Available from: http://tinet.ita.doc.gov/outreachpages/inbound.world_us_intl_arrivals.html
4. Kassianos G. Immunization: childhood and travel health. 4th ed. Oxford: Blackwell Science; 2001.
5. Department of Health. GMS Statement of Financial Entitlements (SFE) 2005 onwards. London: DH: 2005. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
6. Department of Health. FHSL (95)7: Malaria prophylaxis regulation permitting GPs to charge for prescribing or providing anti-malarial drugs. London: DH; 1995. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Fa...