Travel health services in general practice: Important information for all general practice nurses in England

Travel health in general practice has always caused much discussion and divided opinion, never more so than currently when recent actions and instructions to general practice nurses in England about the provision of travel health services have generated a host of queries and concerns. This article is intended to explain the situation in three scenarios and provide information to ensure that GPNs work safely for the care of their patients and within their professional code

1. Stopping all provision of travel health services in an NHS GP surgery

The current GP Contract in England defines travel health as an essential service.¹ In section 5.4 under the title ‘Global sum payment and new core standards’, it says, ’All practices will be expected to offer all routine, pre and post-exposure vaccinations and NHS travel vaccinations.’ The NHS travel vaccines of cholera, hepatitis A, polio (only available in the combined tetanus, polio and diphtheria vaccine) and typhoid, are provided after a pre travel risk assessment, as an important public health intervention.² The purpose is to prevent such diseases, which are highly transmissible, being brought back into the UK by travellers returning from higher risk counties abroad.

2. Incomplete pre travel risk assessments and inappropriate administration of vaccines

Some GP practices in England are still providing the NHS travel vaccines but are opting not to provide the service in full. In some situations, the interpretation of the GP contract to provide ‘Vaccinations and immunisations’ is interpreted as just that, stating that they are ‘not contracted to provide pre-travel advice to patients.’³

This raises two issues of significant concern:

a. This is contrary to advice contained in the RCN Travel Health Nursing: career and competence development guidance,⁴ and the RCPSG Good Practice Guidance for Providing a Travel Health Service.⁵ Each of these guidance documents provides comprehensive advice regarding the pre-travel consultation and a competency assessment tool for practitioners.

b. The accepted standard for the administration of the NHS travel vaccines in general practice is by use of the National Patient Group Direction (PGD) templates for the NHS travel vaccines (signed off locally). Nurses sign these legal documents and operate under them to administer NHS travel vaccines. However, the administration of vaccines causes some concern in practice settings, often because people do not fully understand the legal requirements and the rationale behind them.⁶ The NHS Specialist Pharmacy information on the Introduction to PGDs states ‘the whole episode of care must be undertaken by the health care practitioner operating under the PGD.’ 7 Therefore, the nurse who operates within these legal documents ‘is responsible for assessing that the individual meets the criteria set out in the PGD’ which in a travel health context would include:

• The pre travel risk assessment
• Verifying the current recommendations for travel by NaTHNaC, at https://travelhealthpro.org.uk/countries for country-specific advice and vaccine recommendations
• Obtaining informed consent which requires explanation of the risks/ rationale to a traveller, prior to administration of such vaccines
• Administration of the recommended vaccines
• Documentation of the encounter to fulfil record requirements stipulated within the PGD

Therefore, the instruction from a GP surgery to the patient to find out what travel vaccines they need (either by looking themselves online or visiting a private travel clinic), then returning to the surgery for administration of these vaccines is incorrect and would put the healthcare practitioner who is administering these vaccines at significant risk of violating their professional code.

Risks and disadvantages may also arise for the patient because travel clinics may be difficult to access in some more rural areas, and in general, the traveller would need to pay for the private consultation to assess their risk. Not all travellers are holiday makers,8 or indeed wealthy.

3. Pre travel health risk assessment performed by one nurse healthcare practitioner (HCP) and the administration of the NHS travel vaccines delegated to another HCP

The description of this type of practice is possible by the use of a Patient Specific Direction (PSD), but only if the registered nurse who is performing the pre travel risk assessment is a prescriber and undertakes the whole consultation. The actions would need to include:

• Verifying the current recommendations for travel by NaTHNaC at https://travelhealthpro.org.uk/countries for country-specific advice and vaccine recommendations
• Obtaining informed consent, which requires explanation of the risks/rationale to a traveller in a verbal consultation, prior to administration of such vaccines
• Giving any relevant pre travel health advice.

This individual HCP would then write the PSD and delegate the duty of the vaccine administration and subsequent documentation to another healthcare practitioner. The National Immunisation Standards9 state that ‘those who give travel immunisations will require specific training on travel health – a generic immunisation course alone would not be sufficient.’

Note – and this is of significant importance – if using this method, the national PGD cannot be used to administer the NHS travel vaccines.

The Care Quality Commission (CQC) provides supporting information on these matters – see GP Mythbuster no. 107.¹⁰ It is highly recommended that nurses, GPs and practice managers read this published guidance in full. Nurses using this method should also be aware of the supplementary information to the NMC Code on ‘Delegation and accountability’.¹¹

IN CONCLUSION

The provision of travel health in the current situation, with primary care under severe pressure, may not be viable in the longer term. Indeed, in Scotland, it was decided to remove immunisations from the GP contract in 2018, but it took considerable time to manage how a service would be provided, and it was 2022 before the Scottish Government published its plans for travel health.¹² Each Health Board became responsible for developing a service delivery model most suitable to their local needs and in the majority of situations this was not in GP surgeries. An example of a comprehensive service set up to serve the community in East Lothian can be seen here: https://services.nhslothian.scot/travelclinics/.

In England, work is in progress to transform the delivery of vaccination services,13 but travel health is currently not part of this transformation. A discussion is needed to unravel the complexity and challenges of travel health service care. In the meantime, if travel is to remain in general practice as an essential service, then registered nurses delivering travel health in a general practice setting in England should follow the processes set out in this article in order to work legally, and are reminded that, under the NMC Code, they are accountable for their own practice.

• See also Jane Chiodini's regular Travel update

REFERENCES

1. British Medical Association. gp-contract-agreement-feb-2020.pdf (bma.org.uk) (See 5.4); 2020 https://www.bma.org.uk/media/2024/gp-contract-agreement-feb-2020.pdf

2. British Medical Association. Travel medication and vaccinations; 2022. https://www.bma.org.uk/advice-and-support/gp-practices/vaccinations/travel-medication-and-vaccinations

3. Leicester, Leicestershire & Rutland Local Medical Committee Ltd; 2024. https://www.llrlmc.co.uk/focusontravelimmunisations

4. Royal College of Nursing. RCN Travel Health Nursing: career and competence development; 2023 https://www.rcn.org.uk/Professional-Development/publications/rcn-travel-health-nursing-uk-pub-010-573

5. Royal College of Physicians and Surgeons of Glasgow (2020). Good Practice Guidance for Providing a Travel Health Service; 2020. https://rcpsg.ac.uk/travel-medicine/good-practice-guidance-for-providing-a-travel-health-service

6. Donovan H, Green D, Jenkins J. Best practice for medicines management and vaccination. Practice Nursing 2022;33(11):465-469 https://www.magonlinelibrary.com/doi/full/10.12968/pnur.2022.33.11.465

7. NHS Specialist Pharmacy Service. Introduction to PGDs. https://www.sps.nhs.uk/articles/introduction-to-pgds/

8. Office for National Statistics: Travel trends 2023 https://www.ons.gov.uk/peoplepopulationandcommunity/leisureandtourism/articles/traveltrends/2023#visits-abroad-by-uk-residents

9. UKHSA. Immunisation training standards for healthcare practitioners; 2018. https://www.gov.uk/government/publications/national-minimum-standards-and-core-curriculum-for-immunisation-training-for-registered-healthcare-practitioners

10. Care Quality Commission. GP mythbuster 107: Pre-travel health services - Care Quality Commission. https://www.cqc.org.uk/guidance-providers/gps/gp-mythbusters/gp-mythbuster-107-pretravel-health-services

11. Nursing and Midwifery Council. Delegation and accountability. Supplementary information to the NMC Code https://www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/delegation-and-accountability-supplementary-information-to-the-nmc-code.pdf

12. The Scottish Government. Vaccination Transformation Programme – Travel Health Services; 2022. https://www.publications.scot.nhs.uk/files/cmo-2022-13.pdf

13. NHS England. NHS Vaccination Strategy; 2023. https://www.england.nhs.uk/publication/nhs-vaccination-strategy/

All references accessed 8 September 2024