An IMO delegation met with the Department of Health on 31 August 2011 to outline the issues on the review of fees under the FEMPI legislation and to highlight the value of the service to the public. It was also emphasised the success rates had increased considerably and the value for money provided by general practice. Following the FEMPI submission there was an exchange of views on the proposed expansion of this service to pharmacists.

FEMPI Oral Submission

The position of the IMO as set out in the oral submission was set out as;

1. Population Vaccination programmes are a critical element of the country’s health promotion activities and play a key role in increasing patient well being and reducing down-field health and other costs by preventing illnesses in the population; particularly amongst at-risk groups. The success of these programmes should never be taken for granted.

2. The participation of General Practitioners [GPs] has been critical to the long-standing success of the State’s public vaccination programmes not least because of the high level of public trust which exists with GPs, the comprehensive, trusted distribution system offered by the network of participating GPs and the level of knowledge and access which GPs have in relation to and with at-risk sections of the population and vice-versa. Ireland lagged behind many European countries at the turn of the millennium in relation to vaccination uptake. Great advances have been made in Ireland since first EU immunisation week in 2005. New life saving and disease preventing vaccines are now being used, pneumococcal, meningitis, HPV, soon rotavirus and others will be available. GPs have played a pivotal role in this improvement over the past 10 years.

3. We have seen in recent years attempts to generate public unease/fear about vaccination/immunisation programmes. Any interference in the current, highly trusted system built around GPs may play into the hands of those seeking to undermine confidence in these important programmes.

4. The fees payable to GPs for participation in vaccination programmes can not be judged in isolation as they form part of the broader State payments system for GPs which has always depended on an element of cross-subsidisation to maintain a sustainable GP infrastructure.

5. Given the significant cuts in income from the State already experienced by GPs through three rounds of cuts, including the over 70s and both FEMPI cuts together with the falling number of private patients, individual GPs have made very clear that they will be forced to cease participation in the vaccination programmes should fees be reduced to a level where they are not viable thus threatening the continued success of these programmes.

This will pose significant challenges for the state and the successful delivery of these programmes. Additionally the issues of how the service will be delivered and the costs of that service will be significant.

6. Any cuts in fees for this service would be against the terms of the Public Services Agreement 2010 – 2014 (the Croke Park Agreement) which states in Section 1.15 that – “there will be no further reductions in the pay rates of serving public servants for the lifetime of this Agreement”

7. The support provided by general practice in the provision of immunisation services is invaluable as recently evidenced when GPs in an urban area were able to provide vaccine to all infants under 12 months within 48 hours of a potential measles outbreak.

Expansion of Flu Immunisation to Pharmacists

The information provided by the Department of Health and the HSE on the expansion of the service to pharmacists was set out as follows

• The flu vaccine may be made available through pharmacists to over 65s with a view to increase the level of uptake of the vaccine and provision of vaccination ‘at the lowest level of complexity’.
• GPs may continue to provide the vaccine to patients in the normal way. The vaccine supply provided to pharmacists will be taken from the HSE contingency supply
• The HSE confirmed that the protocols to provide this service as well as the supports in place to deal with adverse events and post vaccination side effects will be issued by PSI and a copy will be provided to the IMO. This will include details of out of hours cover
• The Department of Health are awaiting changes in legislation to enable pharmacist provision of flu vaccine and use of epinephrine
  The IMO Position in relation to these changes is in addition to the points set out to the Minister in a letter which is also attached.

1) There are a multiplicity of responsibilities involved in delivering and supporting a vaccination programme particularly for at risk cohorts of patients such as the over 65 age group. General practitioners successfully deliver the flu vaccination programme to HSE specifications. General practitioners additionally provide flu vaccination services in the domiciliary / residential setting where necessary. It is important that these standards are maintained

2) Doctor involvement in vaccination delivery processes is the normal standard as per manufacturer’s advisories (PILs / SICs), international expert advices (WHO) and normal practice in countries where there is access to general practitioners / PHDs. Normal standards in Ireland are that the responsible general practitioner is present at all times during vaccine administration in case of acute onset, life threatening anaphylaxis from vaccinations.

General practitioners are normally

(i) involved in pre vaccine assessment of the patient’s status and his/her relevant medical and vaccination history

(ii) involved in the process of obtaining informed consent or informed refusal for which an assessment of the patient’s status and his/her medical history is relevant 3) present at all times during the administration of vaccines

(iii) accessible for necessary interventions in relation to post vaccination queries, side effects, and complications, including the provision of 24hr 7 day access to a general practitioner including a domiciliary service where necessary. Flu vaccines have multiple common and uncommon side effects as per manufacturer’s Summary of Product Characteristics (SPCs) – most of which are mild and transient but may need medical interventions.

3) The provision of post vaccination services is the responsibility of pharmacists and Pharmaceutical Society of Ireland (PSI) have been advised accordingly. The details of these are expected by 9 September 2011 and a copy will be provided to the IMO. The IMO has written to the PSI to inform them that GPs have no obligation to provide supports under their scheme.
The IMO position is that pharmacies who plan to engage in vaccination services will make provisions, as general practitioners do at present, for all aspects of the vaccination service including the provision of medical aftercare for patient queries and side effects on a 24hr 7 day basis to include the domiciliary setting.

4) General practitioners have concerns in relation to potential liabilities should they advise or engage with independent enterprises such as pharmacies in relation to their proposed vaccination services including pre, peri and post vaccination issues.

5) General practitioners would not normally engage in service supports or interventions in relation to autonomous service provisions by independent enterprises such as pharmacies, nor are general practitioners contractually obliged to do so under GMS or vaccination contracts. General practitioners would expect that pharmacies planning to offer vaccination services will provide details of their 24hr service provisions including domiciliary provisions in relation to peri and post vaccination complication management. Such peri and post vaccination service provisions should be equivalent to that currently being provided by general practitioners involved in vaccination service delivery.

6) Flu vaccination uptakes by target patient cohorts as defined annually by the HPSC are likely to decrease through the proposed fragmentation of vaccination services. It is internationally recognised that the most effective motivation for patients to engage in vaccinations is general practitioner encouragement. The proposed disassembling of the current general practice based vaccination service in relation to flu vaccine will confuse and fragment vaccination delivery involvement by general practice. That such service fragmentation is planned for a vulnerable cohort – the over 65 age group – displays a gross lack of awareness of the multiplicity of functions involved in supporting and providing a vaccination programme.

7) The proposed fragmentation of vaccination delivery would diminish future general practitioner investments in staff and infrastructure relating to vaccine service provisions. The current ability of general practise to deliver vaccination programmes and to respond immediately to population vaccination needs as has occurred with changing WHO / HPSC flu vaccine indications, measles outbreaks, mumps outbreaks and meningitis outbreaks would diminish accordingly.