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SCHEDULE 2 - THE SERVICES Schedule 2 Part 1: Service Specification SERVICE SPECIFICATION Service Commissioner Lead Integrated Musculoskeletal Clinical Assessment and Treatment Service Emma Haffenden – Commissioning Portfolio Lead, NHS Buckinghamshire Tim Jones – Project Director, United Commissioning Provider Lead Period Document information This is a draft service specification drawn up to support the procurement process. Every effort has been made to ensure that the information in this specification is accurate and it is our expectation that the final specification to be included in the service contract will be substantially the same as this document. However, the commissioners reserve the right to alter this specification up to the point of commercial close. The provider should take careful note of the statements that are prefaced by the text ‘The provider will:’ and are highlighted in bold, italic text as these will form contractual requirements and/or inform the performance framework. Where text or other material is not complete or is likely to change a note has been included in [bold text with square brackets] 1. Purpose 1.1 Aims The purpose of this specification is to set out the requirements for an integrated clinical assessment and treatment service for people with musculo-skeletal complaints. This will serve as an alternative to hospital based treatment for the majority of patients being referred by general practitioners for musculoskeletal (MSK) assessments and for the management of pain that is not neuropathic in origin. Patients w i l l be referred to hospital only when there is a need for hospital based specialist services. The aim is to manage musculoskeletal conditions within an evidenced-based model with an emphasis on supported self-care, improving the quality of services and clinical outcomes, reducing waiting times and increasing access for patients and provide value for money. The service should be provided in accordance with a set of principles that encompass these aims. These principles will guide the provider and commissioner in all aspects of service delivery and will be used to inform the performance management of the service. The provider will: Place the patient at the centre of design and delivery of an integrated service Be committed to close cooperation with all others on the clinical pathway, individually and as an organisation Fit closely with good quality management of MSK by primary care. It is not the intention that the service should take over from care by GPs Work to maximise integration of the service in a way that gives a high quality patient experience and avoids duplication (e.g. multiple assessments) Promote interdisciplinary team care and the Single Assessment Process (SAP) to ensure that an individual’s support needs are considered in a holistic way Support a unified care record Identify organisational barriers to the delivery of patient-centred care and address these 1.2 Evidence Base Clinicians are expected to keep knowledge and skills up to date throughout their working lives and be familiar with relevant guidelines and developments that affect their work (Good Medical Practice, General Medical Council, 2006). This principle extends to all staff engaged in the provision of the service. A commitment to evidence-based practice should be demonstrable through the presence of effective systems, policies and resources. The provider will: Promote the use of evidence-based practice Provide a consistent decision support system for all professionals, including trainees Ensure effective clinical governance and support multidisciplinary clinical audit The evidence base for effective practice is changing constantly and it is not helpful to offer a definitive list of guidance. However, at the time of writing the following publications and standards are particularly relevant: The Musculoskeletal Services Framework, DH 2006 NICE Guidance, Osteoarthritis: The Care and Management of Osteoarthritis in Adults. Feb 2008 NICE Guidance, Rheumatoid Arthritis: The Management of Rheumatoid Arthritis in Adults. Feb 2009 NICE Guidance, Low Back Pain CG88 Lamb et al. Best back education skills training trial published in Lancet 2010 Healthcare Commission — Core Standards The Chartered Society of Physiotherapy and professionals including Occupational Therapists, psychologists, Nursing staff and podiatrists — Core Standards and service Standards The British Pain Society – Guidelines for Pain Management Programmes for adults, April 2007 1.3 General Overview In England, as in the rest of the world, musculoskeletal conditions are common, and are a major cause of ill-health, pain and disability. It is estimated that nearly one-quarter of adults and around 12,000 children are affected by longstanding musculoskeletal problems, such as arthritis, that limit everyday activities. Musculoskeletal conditions are the most common reason for repeat consultations with a GP, making up to 30% of primary care consultations. The prevalence of musculoskeletal conditions generally rises with age and, since the number and proportion of older people in the population is projected to increase in future, so the number of people with musculoskeletal conditions will also rise. However, the functional impairment from musculoskeletal conditions varies widely depending on a variety of physical and psychosocial factors. (Musculo Skeletal Framework, Department of Health, 2007) At present, musculoskeletal services are provided for Buckinghamshire registered patients by: Page 2 of 21 a community based physiotherapy service(across 7 sites plus outreach to local leisure centres and some GP surgeries) receiving referrals from GPs and other community practitioners, Hospital physiotherapy service which is located at Amersham Hospital, Stoke Mandeville Hospital and Wycombe Hospital providing physiotherapy to BHT consultant referrals MSK ICATS (limited scope) provided by Vale Health in conjunction with community based physiotherapy service Chronic Pain & Fatigue Management Service based at Rayners Hedge and Amersham Hospital provided by the community and Integrated Care division of BHT Hospital based care (Trauma & Orthopaedics, Rheumatology and Pain Services). 1.4 Objectives The service will have the following objectives: Improve patient access to MSK services by establishing a community based service and improve the patient experience through improvements in patient satisfaction. Ensure patients are seen and treated in an environment most appropriate to their needs. Develop agreed models of care and pathways for common musculoskeletal conditions. Achieve a reduction of 40% in orthopaedic, rheumatology and pain management referrals to acute hospital providers. Increase conversion rates from outpatient attendances to surgery through more appropriate referrals to acute hospital providers. Reduce waiting times for patients and assist in maintaining the target of a maximum 18 week period from referral to treatment. 1.5 Expected Outcomes The service will have the following expected outcomes: [To be agreed in consultation with the provider at contracting stage] 2. Scope 2. Scope 2.1 Service Description Evidence from other similar initiatives has shown that a separation of ICATS services from primary and secondary care clinicians can have a serious impact on service quality and patient experience. The provider will be required to demonstrate that their service is integrated and that there is real and continuous effort to remove any barriers to effective care and providing a high quality patient experience. How this is achieved is at the discretion of the provider. This aspect of the service will be subject to performance review. Referral and assessment Patients will access the service via three routes: 1. Referral from general practitioners based in NHS Buckinghamshire 2. Referral from other clinician e.g. A&E departments, and non NHS specialists 3. Self-referral The referral can be via choose and book or a paper proforma which can be faxed or posted to the service. Page 3 of 21 If the referral is via the paper proforma the service will transfer the patient details to choose and book. The patient will ideally present with adequate information on which to make clinical assessment as to best destination. Wherever possible the provider should arrange onward care based on this information. However, some referrals will be poor quality, with inadequate information or no information in the case of self referred patients. In these cases in which case patient should be contacted and additional information obtained. This may be through a questionnaire to complete followed by a telephone conversation The provider will: Carry out an assessment of the patient based on information available at referral Obtain additional information if required Arrange onward care If, following a paper triage of a referral, the triaging clinician is of the opinion that the patient should be referred directly to an acute hospital, the referral will be sent back to the GP immediately so that the GP can offer the patient a choice of provider and book the appointment using the Choose and Book system. The GP will be notified of the reason(s) why the referral should have been made directly to an acute hospital. The GP should be notified by FAX if this is the case to avoid any further delay Diagnostics Plain film x-rays should be provided as an integral part of the patient assessment without the need for the patient to make a further appointment. Other diagnostic investigations s h ou l d b e ac c es s e d v i a ref err a l. A list of the treatments and activities included in the service is given at Schedule 2 Annex 3. The provider will: Access appropriate diagnostic imaging and other tests on behalf of the patient Will ensure that results/images are received and used in an appropriate and timely was to manage the patient Ensure that all images/tests are carried out in a timely way to optimise patient care Work closely with providers of diagnostic services to promote integration and ensure a high quality patient experience Treatment The service will be able to assess a wide range of musculoskeletal conditions and make a diagnosis in order to deliver effective, evidence and outcome based management plan. The service will also forge appropriate links with the third sector support and advice groups to offer patients ongoing support if appropriate. A see and treat philosophy is at the heart of this service. It is not intended to act as a referral management centre or gatekeeper or additional tier of service between primary and secondary care. Instead the service will accept referrals and organise care accordingly, referring onward where appropriate. A list of the treatments and activities included in the service is given at Schedule 2 Annex 3. Shared management with the patient’s GP The interface between primary care and the ICATS service must be well-managed if the service is to be truly integrated. GPs will continue to provide comprehensive and holistic care for people with musculoskeletal conditions and will continue to be able to access a range of diagnostic and other tests to support their management of the patient. The provider has an important role to play in ensuring that the ICATS service is used to its optimum. Page 4 of 21 The provider will: Have due regard for the reasons given by a GP for a referral in the assessment and treatment of the patient Provide data to GP practices on their utilisation of the service Provide information to practices to help them improve the quality of patient referrals, in particular: o the completeness of referral forms/letters o any instances where patients have been referred inappropriately Manage discharge appropriately (see section 5) Devise and run a programme of educational events to include the management of the primary care/ICATS interface. The provider should maximise opportunities available of existing programmes, meetings, resources, etc. Prescribing and dispensing There are circumstances when it will be appropriate to prescribe and dispense medicines. The provider will have the required clinical expertise to stock relevant medicines from the agreed formulary in their clinics. A list of the medicines that may be prescribed and dispensed will be agreed (the formulary) . The provider will not hold or dispense controlled drugs. Prescribing decisions and recommendations will only be made by suitably qualified medical independent prescribers. The provider will: Offer patients appropriate medication at assessment where this is indicated. Medication is likely to comprise analgesia The supply of medication shall be 28 days unless otherwise agreed Have appropriate clinical governance procedures in place including a clinical governance lead that will ensure that all prescribing is within national and locally agreed guidelines and treatment pathways. Agree with the commissioner the formulary Management of complex/chronic MSK pain The service will include a chronic pain management service. This will combine physical and psychological pain management programmes for people who have had chronic, including low back pain for anything more than six weeks who have significant psychological distress and or disability and who have had a trail of exercise, acupuncture or manual treatment. The provider will: Work to clear criteria and tools for determining whether patient is at risk of chronic pain with attendant disability and social care costs Provide a multi-disciplinary pain programme to include: o Physical therapy o Occupational therapy o Psychological interventions o Medicines management interventions o Likely 8 - 10 sessions Page 5 of 21 Onward referral If assessment by an orthopaedic surgeon is required the patient will undergo a screening process (BP, urine analysis, BMI) and be offered a choice of surgical provider. When patients are referred on it will be stipulated in the referral the reason for referral i.e. for surgery, a surgical opinion, or because of serious pathology. The provider will: Take responsibility for the patient’s experience of onward referral Ensure that imaging and other clinical information is made available to the service to which the patient is being referred Apply prevailing guidelines in respect of treatment thresholds and priority treatments The patient is booked directly into surgical lists unless excepted on clinical grounds Discharge See section 6. 2.2 Accessibility/acceptability Referral criteria are listed below in paragraph 4.4. 2.3 Whole System Relationships The success of this service will depend on the provider developing good relationships with all those on the pathway for musculo-skeletal care. This is a core aim and principle of the service. See other sections especially Section 3. 2.4 Interdependencies The success of this service will depend on the provider developing good relationships with all those on the pathway for musculo-skeletal care. This is a core aim and principle of the service. See other sections especially Section 3. 2.5 Relevant Clinical Networks and Screening Programmes None at the time of writing 2.6 Sub-contractors The provider may subcontract elements of this service. The provider will: Retain liability for all aspects of service delivery and may not transfer this liability Ensure all sub-contracting arrangements are documented Make available to the commissioner all relevant information to the commissioner relating to sub-contracted arrangements. This will include, for avoidance of doubt, any information that might be considered as commercial in confidence 3. Service Delivery Page 6 of 21 3.1 Service Model 3.1.1 Provide a high quality patient experience The provider will place the patient at the heart of the service at all times. The provider will take responsibility to ensure that the patient receives an integrated service. Provision of evidence-based treatment New evidence for effective treatment should be identified, considered and used to inform clinical practice. The provider will: Offer patients treatment that complies with NICE health technology assessments at all times. Where the provider is not able to do this they must clearly highlight this to the commissioner in writing Have a system in place to promote use of best practice among staff. This might include training, CPD, Have in place a system to review clinical evidence as it emerges and to introduce this into clinical practice without untoward delay Promotion of self-care Self-care and supported self-care are essential components of effective musculo-skeletal care. See section 6. Engaging patients See also section on Self-care. Engaging patients in the design of services and in improvement of the patient experience should be integral to a high-quality, integrated service. Precisely how this is done is at the discretion of the provider however the commissioner does have some minimum expectation and will expect all activities to be auditable: The provider will: Establish a website and portal to provide information to patients, clinicians and other stakeholders. An example of the type of web site is provided on the link below: http://www.eckcommunityservices.nhs.uk/main-menu-pages/your-services/specialist-clinicalservices/integrated-musculoskeletal-services.aspx Make arrangements to carry out patient satisfaction surveys and co-operate with such surveys that may be carried out by the commissioner. The provider shall have regard to any Department of Health guidance relating to patient satisfaction surveys. Use a validated tool to demonstrate clinical benefits of the service. The commissioner expects that this will take the form of a 'before-and-after treatment' assessment tool Collect all data in a way that is auditable and such that the commissioner is able to request regular or ad hoc reports Be expected to demonstrate evidence of having used data and information collected from patients to make improvements to service delivery Co-operate with all reasonable requests by stakeholders (including commissioners, patient groups, local authority/public health) for discussion on service quality and patient experience Quality standards and clinical governance Page 7 of 21 As with all NHS services the compliance with delivery of services in accordance with Good Clinical Practice (General medical Council, 2006) is a minimum requirement. Where a standard or document is cited this shall include all subsequent revisions or successor standards or bodies The provider will: Comply at all times with core standards in ‘Standards for Better Health’ July 2004 or with its Have plans in place, shared with the provider, to achieve the 13 ‘developmental’ standards Comply with relevant Health technology Assessments (guidance) issued by the National Institute for Health and Clinical Excellence. Where the provider is not able to do this they must clearly to the commissioner that this is so and the reasons in writing without undue delay Work to agreed local Integrated Care Pathways and agreed shared protocols and guidelines. Comply with the clinical governance framework agreed by the commissioner and to function under agreed operational and clinical policies. Have in place clear policies aimed at managing risk and procedures to identify and remedy poor professional performance. The provider will have in place a comprehensive and auditable system of clinical governance. This is likely to include: o A Clinical Governance Lead to liaise with a NHS Buckinghamshire designated clinical lead o Incident reporting o Infection control o Significant Event Analysis o Managing Alerts 3.1.2 Manage demand effectively One of the objectives of the service will be to ensure that patients are seen by a health professional in a setting that is appropriate to their needs and offers best value for money. The provider will: Devise and run a programme of educational events to include the management of demand. The provider should maximise opportunities available of existing programmes, meetings, resources, etc. Provide structured, systematic and regular feedback to referrers on the quality of their referrals. This might include numbers of referrals, rates per number of registered patients, disposal of referrals Include systems to audit compliance with agreed treatment guidelines both within the service and along the whole MSK pathway Record sufficient information about their activities and be able to report on the management of all patients 3.1.3 Ensure a high quality workforce The provider is to be given the maximum freedom to use staff in a way that meets the requirements of this specification. Staffing levels Page 8 of 21 Staffing levels and skill mix are at the discretion of the provider. The provider will: Have the appropriate levels of competent staff in order to: o Meet fluctuations in demand o Maintain required waiting times for patients o Properly assess all patients referred to the service o Provide all treatments set out in this specification at all times, without the necessity for referral to other services (See appendix) Employment status Employment and contracting arrangements for staff are at the discretion of the provider. The provider will: Ensure that all staff are eligible to work in the United Kingdom Take responsibility for all actions and practice of all staff and will not be able to transfer any liability for service delivery to any third party Ensure that personnel providing the service through the contract have appropriate l indemnity cover to meet in full, claims made against them as individuals. Proof of cover of the provider must be submitted to the commissioner on request. Ensure that its workforce is able to meet the needs of the service including taking account of: o Professional registration o Criminal Records Bureau checks o Appropriate skills and qualifications o Mandatory training o Training and development plans o Making sure the clinical workforce is able to meet the needs of the patient Staff development The scope and nature of staff development programmes is at the discretion of the provider. The provider will: Ensure that will have an approach to staff development that is consistent, transparent and amenable to audit Ensure that all staff are adequately trained to perform their duties Ensure that staff development is carried out in a way that contributes to the delivery of a high quality service in accordance with this specification Ensure that staff development programmes are auditable at review Ensure that there is adequate clinical supervision at all times 3.1.4 Ensure infrastructure that is fit for purpose An integral service will need to rest on a sound infrastructure that supports the aims of the service. Page 9 of 21 Comprehensive clinical record system An essential component of any service is a clinical record system that captures all relevant clinical data and makes this available in way that supports high-quality, integrated care. An essential secondary function of such a system is the provision of information to allow proper monitoring of service quality, service development and demonstration of value for money. The provider will: Maintain a comprehensive electronic record of care for every patient Hold records on a single database to support service quality and improvement Utilise the information to improve the quality of care Utilise the information to maintain clinical governance Utilise information in planning service improvements Record all relevant clinical and other information according to a data set to be agreed with the commissioner Provide regular and ad hoc reports on service performance as agreed with the commissioner Information Governance High standard of information governance are essential wherever patient identifiable information is collected, processed and stored. The provider will: Will make sure that information relating to patients is managed and safeguarded according to the law and to NHS good practice Ensure that every patient is given the opportunity to consent to their data being accessed for secondary use (e.g. service improvement, contract monitoring, etc) Information Technology Organisations providing services to the NHS are required to work within a framework that promotes increasing integration and standardisation of NHS information and communications systems. The provider will: Work in ways that support national and local programmes and utilises IT in ways that maximise patient care. The Provider will have regard to: • Connecting for Health • Choose and Book • Communication and use of e mail systems Be N3 compliant, be registered with an Information Governance Statement of Compliance (IGSOC) and through registration Authority enable the use of smart cards. Will publish their Directory of Services (DOS) on the Choose and Book system. Participate in PCT audits and data collection and adherence to record keeping. Review of the service The specification will be jointly reviewed by the provider and commissioner with regard to its Page 10 of 21 effectiveness and suitability for patients from time to time. In no way should this service specification preclude the provider from innovating and/or developing new ways of working. Premises and equipment Adequate and appropriate equipment should be available for the clinician to undertake the procedures chosen, and should also include appropriate equipment for resuscitation. The provider will make sure that it has a Business Continuity Plan so that if there are problems with the clinic location or staffing, patients can still access the service. Text to be moved Disabled Access The provider will ensure that wheelchair users and people with poor mobility are able to access services (meeting DDA requirements at all clinical sites). 4. Referral, Access and Acceptance Criteria 4.1 Geographic coverage/boundaries The service should be available to the patients of all practices in NHS Buckinghamshire. 4.2 Location(s) of Service Delivery Patient telephone booking, patient telephone assessment and assessment/triage of clinical correspondence - location not specified Patient face-to-face assessment including x-ray must be delivered from one or more sites within the NHS Buckinghamshire area. Precise locations are not specified but service must be provided with due regard to: Travel time via private car maximum 40 minutes Access via public transport - no more than 5 minutes walking time from bus stop All diagnostic services should be available from providers within the NHS Buckinghamshire area. Patient treatments (following assessment) including physical therapy should be delivered from a range of convenient locations within NHS Buckinghamshire area. Precise locations are not specified but service must be provided with due regard to: Travel time via private car maximum 30 minutes Access via public transport - no more than 5 minutes walking time from bus stop Currently this element of the service is provided from a number of locations. Any change in the number or location of service delivery points may be determined as a major service change. The provider should therefore consider the following as preferred delivery points: High Wycombe Marlow Aylesbury Page 11 of 21 Buckingham Chalfont/Chesham Amersham The provider will: consider the suitability of service delivery points with regard to: o o Therapeutic environment Access for patients with a disability Obtain the views of patients on the location and suitability of service delivery points and makes changes as required 4.3 Days/Hours of operation Hours of operation are at the discretion of the provider. The provider will ensure that some services are provided outside core (9am to 5pm) working hours every week that the service operates. Services will operate every week of the year unless agreed in advance by the commissioner. The service could be available on weekends or Public Holidays. The provider will: Consider the service opening hours with regard to: o o Patient demand as evidenced by call volume and requests for appointments Achievement of waiting time targets Obtain the views of patients on opening hours and makes changes as required 4.4 Referral criteria & sources The service will accept all referred patients and all self-referred patients unless excluded (see 4.6) 4.5 Referral route The service will be available to all patients registered with a GP in NHS Buckinghamshire Patients will be able to self-refer to the service Other clinicians and service providers will be able to refer patients or to direct patients to self-refer to the service. The provider will: Ensure that the service is specified on the Service Directory 4.6 Exclusion Criteria Patients should not be referred to the service where they: Are not registered with a NHS Buckinghamshire GP Have not reached their 16th birthday Require emergency treatment Have with suspected cancer Have post operative or post traumatic complications Page 12 of 21 The service should not be used for patients who have: ‘Red flag’ symptoms - these patients should be referred directly to an acute hospital, including severe pain or constant pain, day and night Pain associated with significant trauma Joint instability where there would be no benefit to the patient in undergoing therapy Patient has a past history of related cancer- red flag Systemic steroids as declared in the GP letter of referral, or discovered at first consultation in the service Systemic illness (fever, malaise, rigors) Significant weight loss suggestive of serious infection or malignancy as declared in the GP letter of referral, or discovered at first consultation in the service Persisting severe restriction of lumbar flexion Widespread neurology with or without upper motor neurone signs Structural deformity Exceptions to the exclusion criteria are set out below: A patient who does not quite fall into the above but nevertheless in the opinion of the referrer there is a clinical case to exclude serious life threatening disease such as cancer (The referrer should indicate on the proforma that in their opinion the referral is not suitable for CATS.) A patient with a very high BMI, with significant co-morbidities or with high ASA scores should be referred into the service only if the referring GP (and subsequent clinical assessment) considers it appropriate; if this is not clear, the provider should refer back to the GP The provider will: Have in place clear policies for managing patients that are excluded or otherwise not suitable for treatment by the service Ensure that all staff are aware of policies and audit practice 4.7 Response time and prioritisation All referrals will be dealt with on a first-come, first-served basis. The service will assess patients and may allocate appointments based on clinical need. Referrals to the service will be assessed as soon as possible by the provider, with all new appointments following a GP referral taking place no more than our weeks from the date the GP referral was received by the provider, unless the patient chooses to attend at a later date (after being offered at least two different appointment dates and two different appointment times within the four weeks). Performance of the provider on response and waiting times will form part of the performance review of the service. The provider will: Work to ensure that waiting times are kept as short as possible Ensure that response and waiting time standards and that any breaches of standards are reported to the commissioner in a timely way. Standards are set out in Schedule 2 Annex 2 5. Discharge Criteria & Planning Timely and well-supported discharge, with effective onward communication is central to an integrated service and high-quality patient experience. Page 13 of 21 The provider will: Make available to the patient’s GP a summary of care including such information as is necessary for management of the patient. This will be in the form of a printed electronic or paper document Ensure that discharge summaries are dispatched to the patient’s GP within the agreed response time – see Schedule 2 Annex 2 for response standards 6. Self-Care and Patient and Carer Information Promotion of supported self care Supported self-management needs to be a guiding principle for this service, informing all aspects of service delivery, most importantly patient interaction. The provider will comply with good practice on supported self-care. How this is incorporated into operating procedures and day-to-day practice is at the discretion of the provider. However, we would expect the following activities to be part of service delivery in a way that is auditable at performance review: The provider will: Offer a comprehensive range of patient information on musculoskeletal conditions, including advice on self-management, and will direct patients to other resources as appropriate Will ensure that clinicians having contact with patients should be trained in shared decision-making with regular updates Give relevant information to patients as to what services to access should a treatment complication arise outside these normal hours Make available all relevant information resources to GPs. The provider may recover the costs of producing this material Information to support choice of treatment Patients will be given an explanation of their condition and advice about all management options which will be discussed with the patient including non surgical and surgical (if appropriate). The provider will: Discuss with the patient relevant treatment options and will make the patient ware of prevailing policies on procedures of limited clinical value The provider shall discuss with the patient This provider will make available to patients the agreed procedure for booking appointments and the policy on DNAs and cancellations. Information for carers The provider will ensure that information is provided for carers that supports the philosophy of supported self care. The requirements set out in the section above will apply also to carers 7. Quality and Performance Indicators Page 14 of 21 Service aspect Quality and Performance Indicator(s) Threshold Method of Measurement Consequence of Breach HCAI Control Service User Experience Improving Productivity [All quality and performance indicators will be devised in collaboration with the service provider at contracting stage. However the provider should take careful note of the statements relating to quality and performance elsewhere in this specification. These will be used to inform the final indicator set] Access Personalised Care Planning Outcomes Additional Measures for Block Contracts:[All quality and performance indicators will be devised in collaboration with the service provider at contracting stage. However the provider should take careful note of the statements relating to quality and performance elsewhere in this specification. These will be used to inform the final indicator set] 8. Activity Activity Performance Indicators Threshold Method of Consequence of measurement breach [Activity targets and expectations will be agreed in collaboration with the service provider at contracting stage] Page 15 of 21 Activity Plan See Schedule 2 Annex 1 9. Continual Service Improvement Plan There is no separate requirement for a plan of this type. Ongoing service improvement will form part of the performance and review process. 10. Prices & Costs 10.1 Price [Activity prices and costs will be agreed in collaboration with the service provider at contracting stage] Page 16 of 21 Schedule 2 Annex 1: Summary of Activity Plans Page 17 of 21 Schedule 2 Annex 2: Summary Quality and Performance Indicators Response and waiting times [All response and waiting times to be agreed with the provider at contracting stage] Definition Response time Telephone answer Contact patients who have been referred or have self-referred to offer an appointment Offer of (first) assessment appointment Offer of treatment (first after assessment) appointment Dispatch of discharge information Page 18 of 21 % achievement Schedule 2 Annex 3: List of treatments and activities This list states which treatments and activities are to be provided in this service and which are to be accessed via referral or other means. [This list is subject to final agreement] Activity Initial assessment of referrals (paper) MSK Initial assessment of referrals (paper) Rheumatology Initial assessment of referrals (paper) Orthopaedics Initial assessment of referrals (paper) Pain (MSK) Initial assessment of referrals (paper)Physiotherapy Initial assessment of patient (face-toface) - MSK Initial assessment of patient (face-toface) - Rheumatology Initial assessment of patient (face-toface) - Orthopaedics Initial assessment of patient (face-toface) - Pain (MSK) Initial assessment of patient (face-toface)- Physiotherapy Type Status Assessment Provide Assessment Provide Assessment Provide Assessment Provide Assessment Provide Assessment Provide Assessment Provide Assessment Provide Assessment Provide Assessment Provide Injection soft tissue - joint (except spine) Injection intra-articular Injection - image guided Injection - spine Procedure Procedure Procedure Procedure Neurophysiology - nerve conduction test Procedure Physical therapy - physiotherapy Physical therapy - physiotherapy (to include exercise) Physical therapy - osteopathy Physical therapy - osteopathy Physical therapy - chiropracty Assessment Order test and manage according to result Order test and manage according to result Provide Order test and manage according to result Order test and manage according to result Order test and manage according to result Provide Provide Refer Refer Order test and manage according to result Provide Treatment Provide Assessment Treatment Assessment Provide Provide Provide MRI scan Imaging Dexascan Imaging Plain film x-ray Imaging Ultrasound Imaging CT scan Imaging Other specialised imaging Imaging Page 19 of 21 Physical therapy - chiropracty Acupuncture Acupuncture Bio-mechanical aids - splints, collars, etc Bio-mechanical aids - splints, collars, etc Mobility aids - mechanical only Mobility aids - mechanical only Orthotics Orthotics Multi disciplinary management of MSK pain Multi disciplinary management of MSK pain Pain management Pain management Rheumatology Rheumatology Orthopaedics Orthopaedics Surgical procedures requiring general anaesthetic Prescription of non-opioid analgesics Prescription of infused medicines - nonexcluded drugs Administration of infused medicines non-excluded drugs Prescription of infused medicines excluded drugs Administration of infused medicines excluded drugs Prescription of injected medicines - nonexcluded drugs Administration of injected medicines non-excluded drugs Occupational therapy Occupational therapy (including home adaptations) Occupational therapy (minor or rehabilitation) Occupational therapy (minor or rehabilitation) Podiatry (MSK only) Podiatry (MSK only) Treatment Assessment Treatment Assessment Fitting Assessment Fitting Assessment Fitting Provide Provide Provide Provide Provide Provide Provide Refer Refer Assessment Provide Treatment Provide Specialist assessment Specialist treatment Specialist assessment Specialist treatment Specialist assessment Specialist treatment Specialist treatment Assessment Provide Assessment Refer Procedure Refer Assessment Refer Procedure Refer Procedure Provide Procedure Provide Assessment Refer Treatment Refer Assessment Provide Treatment Provide Assessment Treatment Provide Provide Page 20 of 21 Refer Refer Refer Refer Refer Refer Refer Phlebotomy Procedure Pathology - blood test Procedure Pathology - other test Procedure Exercise - as part of physical therapy for MSK Exercise on prescription Patient materials to support treatment Choice and booking of provider for specialist care Application of clinical thresholds Application of surgical priorities policies Booking and choice for patients Dietetics and Weight Management Dietetics and Weight Management Provide Order test and manage according to result Order test and manage according to result Treatment Provide Treatment Other Refer back to GP Provide Other Provide Other Other Other Assessment Treatment Provide Provide Provide Refer Refer All activities are for patients aged 16 years and over Page 21 of 21