Vaccine Supply, Fluenz Tetra Ordering
Ordering of Fluenz Tetra for GPs for the children’s flu programme in 2015/2016 is expected to commence week ending 2 October. Ordering will open for the 2015/16 season with no restrictions for either schools or GPs in the first instance. However, the ability to allow free ordering throughout the programme requires customers to adhere to the guidance that has been issued to order/hold no more than 2 weeks stock at any time. Applying restrictions such as an allocation system, or order cap will be considered by PHE at a later date if stock runs low. Fluenz Tetra is a live attenuated vaccine and as such has a very short shelf life. Please bear this in mind when ordering. The first batches will have December 2015 expiry dates. Practices will be able to place an order every week and deliveries will be made weekly alongside usual deliveries of vaccines. Where possible do not order more than required for the next two weeks. This is to minimise vaccine wastage due to the vaccine passing its expiry date before it can be administered. The vaccine will be available to order throughout the entire flu season to ensure there is in date stock available into the New Year. Subsequent deliveries of vaccine will have later expiry dates.

Flu Immunisation for Patients with BMI>40
Practices are advised that there is no obligation to vaccinate patients with BMI over 40 and that no pressure can be applied to practices as this is not about clinical risk, but due to a funding decision by NHS England.

Following national discussion as to whether practices should or should not immunise those with BMI over 40 as per the JCVI recommendations, GPC contacted NHS England for clarification. It has confirmed that there will be no changes to the current enhanced service to include the morbidly obese as a stand-alone cohort, as the recommendation for this cohort came in after the funding had been secured for 2015-16. The wording in the service specification addresses this (page 24, footnote 33 of the specification): ‘33 JCVI have advised that morbidly obese people (defined as BMI>40) could also benefit from a seasonal influenza vaccination. Many of this patient group will be eligible for vaccination under another risk category due to other health complications that obesity places on them. However, funding has not been agreed to cover this cohort as part of this ES. Practices are able to use clinical judgment to vaccinate patients in this group, but vaccinations for morbidly obese patients with no other risk factor are not eligible for payment under this ES. The inclusion of this cohort in subsequent years is under consideration. In addition NHS England confirmed that the morbidly obese are not included in the pharmacists additional service so they should not be directed to pharmacists unless recommending a private vaccination. If practices find themselves with flu vaccinations left over due to pharmacists’ activity, the obese (of any BMI) might be an appropriate population to use them up on.

Guidelines on Malaria Prevention in UK Travellers Update
The Advisory Committee on Malaria Prevention (ACMP), an expert advisory committee of Public Health England (PHE) has updated its guidelines on malaria prevention for medical professionals and other travel medicine advisors based in the UK. The key changes are:

• updated guidance on the use of insect repellent and sun protection

• clarification on the use of hydroxychloroquine

• updated guidance on the use of anticoagulants with antimalarials

• updated guidance on the use of doxycycline in epilepsy

• changes to the country recommendations for Vietnam and Malaysian Borneo, and clarifications on the recommendations for India

• clarification of advice for travellers moving through areas where different antimalarials are recommended

Recommendations for antimalarials should be appropriate for the destination and tailored to the individual, taking into account possible risks and benefits to the traveller. As part of an individual stringent risk assessment, it is essential that a full clinical history is obtained, detailing current medication, significant health problems and any known drug allergies. A suggested risk assessment template is included with the guidelines.

ACMP position on the use of mefloquine
Falciparum malaria is a common, preventable and life-threatening infection. Mefloquine is an extremely effective antimalarial and is currently recommended as one of a number of antimalarials for travellers to high risk areas following an individual risk assessment. During the ACMP meeting in June, the committee reviewed current evidence on the use of mefloquine (proprietary name Lariam), including data provided by the manufacturer Roche, and recommendations on the use of mefloquine for malaria prevention made by other countries. The ACMP concluded that all the currently available evidence had been examined and, on the basis of this, determined that there should be no changes to existing ACMP recommendations regarding mefloquine. Details on the use of mefloquine in travellers, including contraindications and drug interactions are detailed in section 4.2.4 of the revised guidelines.

NHS Property Services Warning Note
It has been brought to our attention that in presenting Heads of Terms and a pro forma lease, NHSPS are intimating that they follow a format that is reflective of the national template documents currently under negotiation between NHSPS and GPC.  In addition GPC are aware of suggestions being made by NHSPS that these documents are largely agreed and that such statements are being used to encourage practices’ to sign up. In both cases such statements are misleading. To be absolutely clear, the national template lease and supporting Heads of Terms under negotiation have not been agreed. As it stands there are fundamental issues that remain outstanding and GPC await a response from NHSPS and NHS England to their letter which sought to have these addressed. For your reference these outstanding issues include, without limitation, the fact that there remains a fundamental discrepancy between the rent review provisions being sought and the sums that are capable of reimbursement. As a consequence of the above we would not recommend that practices sign anything unless they have taken appropriate legal advice and are 100% happy with the terms therein. Please note, in providing this warning GPC would like to stress that there is no legal obligation for practices to sign any such Heads of Terms, or related lease documents. Indeed, it is highly likely that any practice that is in occupation of NHSPS premises without a formal lease will be regarded as “protected” business tenants under the Landlord & Tenant Act 1954. As “protected” tenants practices’ would effectively have a statutory right to remain in occupation. There are very limited exceptions to this and even where these exceptions apply they can only be invoked where a formal statutory process is followed by the landlord. If you are in any doubt as to your statutory rights and strength of position to remain in occupation (or are in any doubt given pressure being exerted by NHSPS) seek legal advice. Once the outstanding issues have been addressed in a manner which does not expose practices to unreasonable risks or burdens, GPC will look to agree the final version of the standard lease and Heads of Terms. As soon as this occurs we will formally issue confirmation that the negotiations have been successfully and satisfactorily concluded and issue guidance notes on the agreed pro forma lease. Until this occurs the position remains that GPC has not agreed the standard lease nor any form of Heads of Terms.

Sessional GP Newsletter
This month’s sessional GPs e-newsletter focuses on the national occupational health service for GPs suffering from stress and burnout and a further update on what GPC are doing to change the unfair rules on death in service benefits for locum GPs. Included in the blogs this month is one from sessional GPs subcommittee member Mary Anne Burrow on doing out-of-hours work.