Download Service Dossier 2014-15

Locally Commissioned Services
Service Specifications Dossier
2014-15
Contents
Page
Administration of POCT (point of care testing) in a hub practice
2
Anti-coagulation monitoring level 4
7
Care planning integration with diabetes annual review
10
Clinical triage for point of care testing (POCT)
16
Dyspepsia in adults in primary care
20
Administration of gonadorelin analogues
23
Insulin services for diabetes in primary care
25
Lead practice for POCT (point of care testing)
30
Minor injuries (comprehensive) service specification
35
Minor surgery
52
Near patient testing
57
Neonatal checks
61
Practices may only deliver those services that they have declared on the Contracts for
Extended Services 2014-15 document.
1
PILOT LOCALLY COMMISSIONED SERVICE
SERVICE SPECIFICATION
Administration of Point of Care Testing in a HUB Practice
1. Introduction
This service specification details the implementation of the Point of Care Testing (POCT) for
cardiovascular conditions in a HUB. It covers the administration of the test, the supervision of the
test administration and clinical governance arrangements to ensure the efficacy of the testing
regime by a practice operating as a HUB.
Initially two tests are being provided: D-Dimer for suspected DVT and BNP for suspected Heart
Failure. These form part of a wider programme that includes the use of Community Cardiology
Services for Heart Failure and for further assessment and treatment of DVT.
All GP practices are expected to sign up for the first part of the pathway (the POCT Service) and
provide clinical triage using a protocol and a screening tool. They will then refer suitable patients to
a practice acting as a test hub, and take subsequent action depending upon the results of the test.
2. Aims
2.1
The overall aim of the programme is to serve the needs of GPs and their patients when a
patient presents with symptoms possibly indicative of certain cardiovascular conditions
(DVT, HF, etc) so that the patient is quickly placed on the appropriate treatment pathway or
are negatively assessed and either treated for an alternate condition or reassured.
2.2
The first specific aim of this HUB Service is to ensure that all tests are performed and
supervised in a consistent and safe way. Consistency is required to ensure that testing
efficacy supports the overall efficacy of the testing regime.
2.3
The second specific aim of this HUB Service is to ensure that the Hub Practice has a means
to act upon a “Red Flag” actions should one be needed.
2.4
The overall measurable outcomes of the programme are:



A reduction in secondary care referrals for suspected DVT. Initially referrals will only
include probable DVT, and depending upon the results of a pilot of community
Doppler Testing, community treatment may also be initiated.
A reduction of secondary care referrals for suspected Heart Failure to only include
patients whose Heart failure indicates the need for secondary care intervention. All
other patients whose BNP is abnormal will be seen by community cardiology
services.
Inclusion of GPs and Hub GPs and Staff in the register of training.
3. Background
This HUB Service forms part of an overall programme to maximally use Point of Care Testing and
treatment in the community for certain cardiovascular conditions where acute intervention is not
required.
The overall programme has the following components:
-
This POCT Service enables all GPs to clinically triage for the conditions improving efficacy of
screening and supporting the patient with suitable medical management.
2
-
-
-
Several practices acting as Hubs (provided through the HUB Service) that support all GPs
by providing a near practice that has agreed to undertake tests as close to “on demand” as
practical and to ensure that all tests are conducted to a safe and consistent standard.
A Lead Practice (provided through a Lead Practice POCT Service) that sets the protocols,
proformas and scoring systems appropriate to each test, provides a service web address,
training material and training for Hubs and GPs, and supervision of audit through Hubs.
An arrangement for further tests to be piloted (normally by GPs that are part of the
Community Cardiovascular Services) and rolled out after careful evaluation.
Community Cardiovascular Services that provide relevant treatment and advice and
guidance to GPs.
The design of the process used is based on the prior experience of the 2009-2012 DVT Local
Enhanced Services, pilot on other tests and NICE guidance.
4. Service Outline
4.1
Personnel: The HUB practice will identify to the Lead Practice the following named
personnel:




A Lead GP,
Alternative Lead GP,
Lead Nurse or Health Care Assistant
Administration Contact
4.2
Notification: Where there are changes in the named personnel, these will be notified.
Notification will be by e-mail to the Lead Practice, details of which are as follows:Toni Fisher, Practice Manager, Whaddon House Surgery. Tel: 01908 373058 or
[email protected]
4.3
Training: Each HUB practice will attend training and accreditation for each named member
of the HUB testing team. Where a member changes, additional training may be provided
through shadowing the operation of HUB in the lead practice. Trained personnel will be
provided with certificates of training and competence.
4.4
Audit and Refresher Training:
The HUB practice will participate in audits and attend annual audit and training meeting
organised by the Lead Practice. Such meeting will introduce refinements and further
developments of the testing regime. They will also include: incident discussions, clinical
discussions related to the conditions under test and refresher training.
4.5
Adverse and Critical Incidents: All incidents including complaints identified by any hub
provider will be reported, logged and investigated by the Lead Practice.
4.6
Point of Care Equipment: The Point of Care equipment will be provided to the Practice by
the Lead Practice. The Practice will be responsible for equipment maintenance,
consumables availability and use and equipment assay. The Lead Practice will provide
guidance and the group of Hubs may collectively manage some aspects of equipment
maintenance and consumables provision.
4.7
The Hub Service: the Practice will ensure the capability of any GP to book, via a telephone
call, an appointment for a HUB service within the next four hours.
A nurse or healthcare assistant will conduct the test acting upon the proforma provided,
normally via NHS.NET. If the proforma is inadequate in any way they will take direction from
a GP in the practice, which may include refusing to undertake the test. Where necessary
they will take a venous blood sample or use the sample provided and processes it. The
sample processing time can take up to fifteen minutes.
3
If the patient is present they will be asked to wait. If the test results are equivocal the
patient may be re-tested. Test results and re-testing are all recorded or attached to the
proforma
If test results coupled with proforma have a “Red Flag” status and the patient is present a
GP responsible for the Hub will initiate any “Red Flag” action and advise/discuss with the
referring GP. If the patient is not present the GP referrer for the Hub will be advised by the
Nurse or HCA conducting the test at the time, or if not possible as soon as possible by a GP
responsible for the Hub.
Where there are no “red flag” the result will be passed back to the referring GP for action
using NHS.NET e-mail.
The Hub will document and record the test and results including keeping a copy of the
proforma. This will be used for audit and service development purposes.
4.8
Information gathering: the HUB will complete monthly and quarterly returns to the
commissioner which will be used for activity monitoring and payment to HUB and referring
practices.
For payment purposes, the HUB practice must complete the 2014/15 Enhanced Services
Evidence & Claim forms (Appendix 1) which should be emailed to:
[email protected] monthly, every month in Microsoft Excel format
only.
Monthly anonymised patient activity to be provided as evidence should include the following
detail:
o
o
o
o
o
o
Patient ID Number (anonymised).
Date of Birth
Name of Patient’s Home Practice
Type of Test Conducted : D-Dimer or BNP
Read code.
Date treatment done.
Failure to send this information to the CCG will result in a nil payment.
For audit purposes, an additional form (Appendix 1) should be completed by each HUB
Practice on a quarterly basis (Oct 14, Jan 15 and Apr 15) and e-mailed to the Lead Practice
using the following address: [email protected]
The content and format of the monthly return may be modified from time to time by either the
Commissioner or the Lead Practice for use in the next return.
5. Performance requirements
5.1
The (Hub) Practice shall use the relevant latest proforma for the Hub service.
5.2
The (Hub) Practice shall ensure that test results are returned to the referring GP via the
NHS.NET within 30 minutes of test completion.
5.3
The (Hub) Practice shall ensure that “Red Flag” results are acted upon within 30 minutes of
test completion.
5.4
In order to maintain competency the (Hub) Practice will conduct at least six tests per month.
4
5.5
In order to maintain service level each (Hub) Practice will be available for at least 220 days
per annum during GP opening hours of 08:00 to 16:30.
5.6
The Practice shall, if required by the Commissioner, open its NHS.NET e-mail records and
service-specific clinical records of patients using the programme to an audit conducted by a
suitable person.
6. Management and Governance
6.1
Training Responsibility – the Practice is responsible for ensuring that individuals operating
under this Hub LES are adequately trained and have been registered with the Lead Practice
as having been trained.
6.2
It is the Practice responsibility to ensure training and competencies of clinicians delivering
this service are kept up to date.
6.3
Adverse and Critical Incidents: all incidents about the service including patient complaints
will be passed to the Lead Practice for investigation, the results of incident investigations will
be made available to all practices.
7. Dispute resolution
7.1
It is in the interest of both the Practice and the Commissioner for any disagreement to be
resolved locally, firstly by the Parties key managers and, in the event of any failing
agreement, the Commissioner’s dispute resolution shall be followed.
8. Termination of contract
8.1
Termination by agreement
8.1.1
The Commissioner and the Practice may mutually agree in writing to terminate the contract
and if the Parties so agree, they shall agree the date upon which termination shall take effect
and any further terms under which the contract shall be terminated.
8.2
Termination by notice
8.2.1
The Commissioner or the Practice may terminate this contract by serving three months
notice in writing.
8.3
Termination for non-performance
8.3.1
The Commissioner may terminate this contract through a failure of performance. The notice
period of termination shall be at the Commissioner’s absolute discretion depending upon the
seriousness of the breach of performance and the extent to which any breach is correctable.
8.4
Record keeping on notice
8.4.1
Where the service is terminated earlier than the term of this agreement, the (Hub) Practice
will meet any requests from the Lead Practice to supply copies of Hub activity records,
including completed proformas and test results.
9. Finance
9.1
Referring practices are not required to submit activity data: the records produced by a HUB
on attendance for a test are used to initiate payment to the Practice.
5
9.2
Payments will be made monthly to practices following acceptance of the data by the
commissioner. Acceptance does include reasonable checks that the data is accurate and
complete, and data may be returned to Hub Practices for correction and re-submission.
9.3
Where the performance of the Practice does not meet the required standard set out in this
agreement, a deduction as agreed by both Parties may be made.
9.4
The sums payable by the Commissioner to the Practice for the provision of this service shall
be the contracted price. All other costs, charges, fees and expenses shall be the
responsibility of the provider.
9.5
The (Hub) Practice will receive a contribution to expenses for the attendance of two GPs and
other relevant staff at annual audit meetings. The Contribution will be £125 for each GP
attending.
9.6
A tariff of £70 will be paid to the (Hub) Practice for conducting each test and undertaking
their other duties under this Hub Service.
9.7
Payments under this scheme are inclusive of all superannuation (both employers and
employees) and the Commissioner has no further liability.
10. Audit
10.1
MKCCG reserves the right to enter a practice and obtain access to relevant records to
undertake an audit of the enhanced service at any time. The objective of the audit would be
to ensure that this contract provides value for money to the CCG. The audit would check the
adequacy of controls, the integrity and reliability of information for billing in the area under
review. This is to ensure that payment is only made for valid work completed. The scope of
the audit does not include checks on the quality of activity. Practices would be given one
weeks notice of attendance and will be required to make the necessary records available.
Each auditor would have appropriate authority from the CCG, treat any records viewed with
confidentiality, and provide clear ID.
Appendix 1
Administration of Point of Care Testing in a Hub Practice Audit Form
Y:\DVT\REVISED
LESs\POCT HUB LES Dataset.xls
6
ANTI-COAGULATION MONITORING LEVEL 4
Specification for a Locally Commissioned Service
1st April 2014 – 31st March 2015
Introduction
Warfarin is being used in the management of increasing numbers of patients and conditions
including patients post-myocardial infarction, atrial fibrillation, DVTs and other disorders. While it is a
very effective drug in these conditions, it can also have serious side effects, e.g. severe
haemorrhage. These side effects are related to the International Normalised Ratio (INR) level, which
measures the delay in the clotting of the blood caused by the warfarin. While the “normal” INR is 1,
the specific range of INR values depends on the disease and the clinical conditions. Warfarin
monitoring aims to stabilise the INR within set limits to help prevent serious side-effects while
maximising effective treatment.
Aims
An anti-coagulation monitoring service is designed to be one in which:





therapy should normally be initiated in secondary care, for recognised indications for
specified lengths of time
maintenance of patients should be properly controlled
the service to the patient is convenient
the need for continuation of therapy is reviewed regularly
the therapy is discontinued when appropriate
Service Outline
The service must be provided to all eligible patients
Development of a Register
Call and Recall
Professional Links
Referral Policies
Practices should be able to produce an up-to-date register of all
anti-coagulation monitoring service patients, indicating patient
name, date of birth, the indication for, and length of, treatment
including the target INR
To ensure that systematic call and recall of patients on this
register is taking place either in a hospital or general practice
setting
To work together with other professionals when appropriate.
Any health professionals involved in the care of patients in the
programme should be appropriately trained
When appropriate to refer patients promptly to other necessary
services and to the relevant support agencies using locally
agreed guidelines where these exist
Education
and
Diagnosed Patients
Newly To ensure that all newly diagnosed patients (and/or their carers
and support staff when appropriate) receive appropriate
management of, and prevention of, secondary complications of
their condition including the provision of a patient-held booklet
Individual
Management To prepare with the patient an individual management plan,
Plans
which gives the diagnosis, planned duration and therapeutic
range to be obtained
Clinical Procedures
To ensure that at initial diagnosis and at least annually an
appropriate review of the patient’s health is carried out including
checks for potential complications and, as necessary, a review
of the patient’s own monitoring records.
To ensure that all clinical information related to the service is
7
Prescribing Guidance
Record Keeping
Audit
Training
Review
recorded in the patient’s own GP held lifelong record, including
the completion of the “significant event” record that the patient is
on warfarin
To follow the prescribing guidance within the CCG ‘Prescribing
and Medicines Management Strategy’.
To maintain adequate records of the performance and result of
the services provided, incorporating appropriate known
information, as per NPSA guidelines. This may include the
number of bleeding episodes requiring hospital admission and
deaths caused by anti-coagulants
To carry out clinical audit of the care of patients against the
above criteria, including untoward incidents. This should also
review the success of the practice in maintaining its patients
within the designated INR range as part of quality assurance.
The NPSA has issued specific guidance on safety indicators
which should be followed.
Each practice must ensure that all staff involved in providing any
aspect of care under this scheme have the necessary training
and skills to do so
All practices involved in this scheme should perform an annual
review which could include:
 information on the number of patients being monitored,
the indications of anti-coagulation, e.g. DVT etc., and the
duration of treatment
 brief details as to arrangements for each of the aspects
highlighted above
 details of any computer-assisted decision-making
equipment used and arrangements for internal and
external quality assurance
 details of any near-patient testing equipment used and
arrangements for internal and external quality assurance
 details of training and education relevant to the anticoagulation monitoring service received by practitioners
and staff
 details of the standards used for the control of anticoagulation
Performance Monitoring
As a minimum, practices will need to ensure they keep activity information that records the
interventions carried out at an individual anonymised patient level as per NPSA safety indicators.
Clear identification of the practitioner who carried out the intervention needs recording. .
Untoward Events
It is a condition of participation in this service that practitioners will give notification to the CCG
clinical lead of all emergency admissions or deaths of any patient covered under this service, where
such admission or death is or may be due to usage of the drug(s) in question or attributable to the
relevant underlying medical condition. This must be reported within 72 hours of the information
becoming known to the practitioner. This is in addition to a practitioner’s statutory obligations.
Accreditation
Those doctors who had previously provided services similar to this enhanced service and who
satisfy at appraisal and revalidation that they have such continuing medical experience, training and
competence as is necessary to enable them to contract for the enhanced service shall be deemed
professionally qualified to do so.
Finance
8
In 2014/15 each practice commissioned to provide this service will receive:
£113.23 per patient per year for level 4 service i.e. Practice-funded phlebotomist, practice sample,
practice test, practice dosing
The
practice
will
submit
the
following
information
to
the
CCG
electronically
to
[email protected] monthly, every month in Microsoft Excel format only:
o
o
o
o
Patient ID Number (anonymised).
Read code.
Read code description.
Date treatment done.
Failure to send this information to the CCG will result in a nil payment.
In addition practices providing a Level 4 service should invoice the CCG quarterly for reimbursement of payment for test strips. Based upon current information the CCG would expect
practices’ usage to be approximately 4 test strips per patient per quarter, where practices
consistently claim for higher levels than this they may be required to provide more information to the
CCG. Please note FP10’s must not be submitted for test strips used for this service.
Audit
MKCCG reserves the right to enter a practice and obtain access to relevant records to undertake an
audit of the enhanced service at any time. The objective of the audit would be to ensure that this
contract provides value for money to the CCG. The audit would check the adequacy of controls, the
integrity and reliability of information for billing in the area under review. This is to ensure that
payment is only made for valid work completed. The scope of the audit does not include checks on
the quality of activity. Practices would be given one weeks notice of attendance and will be required
to make the necessary records available. Each auditor would have appropriate authority from the
CCG, treat any records viewed with confidentiality, and provide clear ID.
Termination/Alteration
The provider will give at least 3 months’ notice of the intention to terminate this agreement. In
exceptional circumstances the CCG may agree to reduce this period.
The CCG will give at least 3 months’ notice of any intention to change or terminate this agreement
allowing for the fact that currently the service runs to 31st March 2014.
Service Specification for a Local Enhanced Service – Anti-coagulation monitoring Level 4
All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. The specification of this service is designed to cover the enhanced
aspects of clinical care of the patient, all of which are beyond the scope of essential services. No
part of the specification by commission, omission or implication defines or redefines essential
services.
9
LOCALLLY COMMISSIONED SERVICE
TO SUPPORT CARE PLANNING INTEGRATION WITH DIABETES ANNUAL REVIEW
April 2014 – March 2015
1.
Introduction
All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. The specification of this service is designed to cover the enhanced
aspects of clinical care which is beyond the scope of essential services. No part of the specification
by commission, omission or implication defines or redefines essential or additional services.
2.
Background
Standard 3 of the Diabetes NSF highlights the importance of empowering people with diabetes to
take an active role in managing their condition:“ All children, young people and adults with diabetes
will receive a service which encourages partnership in decision-making, supports them in managing
their diabetes and helps them to adopt and maintain a healthy lifestyle. This will be reflected in an
agreed and shared care plan in an appropriate format and language. If appropriate, parents and
carers should be fully engaged in the process.”
The NSF stated that “A care plan is at the heart of a partnership approach to care and a central part
of effective care management. The process of agreeing a care plan offers people active involvement
in deciding, agreeing and owning how their diabetes will be managed. Whilst the overall goal is a
genuine partnership, the person with diabetes must feel that they are comfortable with what is
proposed and that they do not have to bear more responsibility than they wish”.
Our Health, Our Care, Our Say (DH 2006) sets a new direction for the whole health and social care
system. Services will be designed around the individual, rather than the needs of the person being
forced to fit around the service already provided. The emphasis is on supporting self-care,
promoting well-being and community engagement, as well as prevention and early intervention.
There will be more support for people with long term conditions who will be encouraged to manage
their conditions themselves with the right help from health and social care services.
The Health Care Commission Service Review of Diabetes found that while 95% of people with
diabetes had annual checks less than half discussed their goals in managing their condition. Care
Planning is a process which offers people active involvement in deciding, agreeing and owning how
their diabetes will be managed.
2.
Purpose of the Service
While practices are integrating care planning with their Diabetes annual review process extra
time will be required from clinicians to implement new methods of consultation and additional
administration time will be required to set up the processes. The purpose of this service is to
support this integration and change. Funding will be available to a practice for 30 months from
when a practice is commissioned to provide this service.
3.
Aims



To develop a partnership with people to enable them to manage their condition
To minimise avoidable complications of diabetes
To move towards a future service where Care Planning is the ‘norm’.
10
4.
Outcomes
People with Diabetes
 Greater satisfaction
 More effective diabetes care consultations
 Better understanding of their condition, goals and ways of working
 Optimal health and quality of life outcomes
 Successful self-management
 Active involvement in decision making
 Planning care they are more likely to want to follow through.
 Agreeing an enhanced, clear, and predictable programme of care
Clinicians
 More satisfaction in consultations
 Assuming less direct responsibilities for outcomes (allowing the patient to assume greater
responsibility for their own health)
 The Care Planning approach increases the chance of successful behaviour change
 Being able to measure their activity through audit and quality assurance standards to show
the impact of their work
Commissioners
 Able to commission services that people want to experience and clinicians want to provide
 Offers measurable assessment of an individual’s needs or goals to guide commissioning of
appropriate services
 Facilitating systematic diabetes care
 Potential to reduce admissions
 Improves patient satisfaction
 Care Planning approach has measurable outcomes
 Increasing effective self-management, identified in the Wanless report as being important to
reduce increases in health service expenditure
5.
Client Group
People on the practice’s register who have diabetes and are age 17 years and over.
6.
6.1
Service to be provided
Prior to the care planning meeting
6.1.1 The provider must ensure the person with diabetes receives their test results with an
explanation sheet about the results, a minimum of one week before the care planning meeting. This
will include:






Hba1c results
Blood pressure
Cholesterol & blood lipids
Kidney tests, EGFR and Micro albuminuria
Weight & BMI
Smoking
6.1.2 The provider must also ensure that:


The person with diabetes has the relevant information to understand their test results
The person with diabetes is given examples of questions they may wish to ask at the care
planning meeting
11
6.2
Agenda setting at the care planning meeting
6.2.1
The provider must ensure that:



6.2.2





The health care professional and person with diabetes agree the agenda
The health care professional must use a collaborative and partnership approach with the
person with whom they are consulting
The health care professional has good listening skills
The agenda should include:
The aims, objectives and concerns of the person with diabetes
A review of the previous care plan
Sharing and discussing results
Sharing information about local services available to meet the objectives of the person
Detailed information should be available about the risks and benefits of treatment options
(these should be personalised as much as possible)
6.3
Supporting patients to set goals and reach decisions
6.3.1
The provider must inform, encourage and refer as appropriate all people with newly
diagnosed type 2 diabetes to the ‘DESMOND’ diabetes self-management education course
(within one year of diagnosis)
People with Type 1 diabetes and people who have type 2 diabetes who are not newly
diagnosed should be referred to a group education course as appropriate, as and when
available and at a time appropriate to them.
6.3.2
The provider should make sure that the health care professional uses skills and techniques
to support the person with diabetes in setting their goals, these include:

Develop a partnership with the patient

Establish or review the patient's preferences for information (such as amount or format)

Establish or review the patient's preferences for role in decision making (such as risk taking
and degree of involvement of self and others) and the existence and nature of any
uncertainty about the course of action to take

Ascertain and respond to patient's ideas, concerns, and expectations (such as about disease
management options)

Identify choices (based on ideas and information that the patient may have) and evaluate the
research evidence in relation to the individual patient

Make or negotiate decisions in partnership with the patient and resolve conflict

Negotiate an action plan and complete arrangements for follow up.
6.4
The Care or Action Plan
6.4.1
The provider must ensure that the person with diabetes and health care professional agree a
set of action points. This will include:





What the action is and why they have agreed it?
Achievable actions and targets are agreed
Who is responsible for the action?
What is the Timescale? E.g. for referral, investigation…
When will this be reviewed?
12
6.4.2
The paper and electronic care plan
6.4.3
The provider must ensure that an electronic and hard copy care plan is produced and
agreed by both parties.
6.4.4







6.5
The care or action plan will be locally devised, however certain key themes are standard,
which are detailed below.
Current situation - New Data
Outcomes/progress against goals (if there has been a previous care planning meeting)
Concerns/Problems (Individuals/Health Care Professional’s)
Goals
Actions by health professionals to achieve goals
Actions by person with diabetes to achieve goals
Concerns for future consideration
Care planning and Black and minority ethnic communities (BME)
The provider needs to consider and make provision with care planning for delivering a
service to ethnic communities. These will include:



6.6
Information in language specific formats both in hard copy and web based
Independent interpreters at care planning meetings/review
Links with local BME community groups
Care planning and people with disabilities
The provider will need to consider and make provision for people with diabetes who have a
disability when care planning. This will include people with learning disabilities. The provider
must consider support with:
Language needs – Makaton, BSL, Deaf/blind communication, picture boards, Braille, large
print, audio
Advocacy – particularly for people with learning disabilities
Access - building, toilets, outreach approach
6.7
The Menu of services
6.7.1
The provider must have a care planning workforce that is a source of knowledge concerning
the menu of services available to people with diabetes. This includes:


6.7.2








An up to date knowledge of local , national services and support
Staff that can disseminate this information in a consultative and collaborative approach
Services and support includes:
Group education (as available)
Medication
The range of primary, secondary and tertiary care
Podiatry
Dietetics and weight loss support
The Voluntary sector
Help lines
Diabetes UK details
13



Leisure and fitness facilities
Other health support – psychological etc
Links to housing, social services, education etc
7.
Accreditation to provide the Service
7.1
The provider must verify that all appropriate staff required to deliver the service specified in
section 6 of this specification have attended Care Planning training i.e. a GP, a nurse and
HCA or admin. This will be one full day initial training and one half day follow-up training.
(Training will be provided by a service contracted by the CCG to provide)
7.2
The lead GP and nurse would be expected to undertake annual educational update of at
least half a day.
7.3
A GP and/or nurse who has a Warwick certificate in Diabetes Care (or equivalent) would
be desirable.
8.
Monitoring and Evaluation
8.1
Practices providing this service must undertake a Continuous Quality Improvement (CQI)
survey for a sample of 25 - 50 patients per year and provide the report data to MKDC to
analyse and send to the CCG on the scores by 31st March each year.
8.2
The CCG will monitor the practice achievement for Diabetes indicators in the Quality &
Outcomes Framework
8.3
To attend annual educational updates
8.4
One appointment a year with MK Diabetes Care to check the service is being followed and
to discuss care planning progress and CQI results.
8.5
The lead GP and nurse would be expected to undertake a 24 monthly update in Care
Planning diabetes educational update of at least half a day.
9.
Payments
As part of this agreement it is assumed that the practice currently allow a minimum of 20 minutes
with health care professional/s to meet QOF diabetes indicators.
The practice will receive a payment of £16.16 per Care Planning Annual Review.
The practice will submit the following information to the CCG electronically to
[email protected] monthly, every month in Microsoft Excel format only:
o
o
o
o
Patient ID Number (anonymised).
Read code. Suggested read code: XaKSn. Diabetes care plan agreed
Read code description.
Date treatment done.
Failure to send this information to the CCG will result in a nil payment.
Practice teams will not be paid to attend training.
14
Disputes – Conciliation, Arbitration, and Appeals
10.
In the event of disagreement or dispute, the CCG and the practice will use best endeavours to
resolve the dispute without recourse to formal arbitration. If unsuccessful, the matter will be
determined in accordance with the normal contractual dispute resolution procedure.
11.
Termination
A period of 3 months notice is required to terminate this service, which can be given by either party,
otherwise the agreement ceases on 31st March 2015.
12.
Financial audit
MKCCG reserves the right to enter a practice and obtain access to relevant records to undertake an
audit of the enhanced service at any time. The objective of the audit would be to ensure that this
contract provides value for money to the CCG. The audit would check the adequacy of controls, the
integrity and reliability of information for billing in the area under review. This is to ensure that
payment is only made for valid work completed. The scope of the audit does not include checks on
the quality of activity. Practices would be given one weeks notice of attendance and will be required
to make the necessary records available. Each auditor would have appropriate authority from the
CCG, treat any records viewed with confidentiality, and provide clear ID.
References
•
•
•
•
•
•
Department of Health (2006) Care Planning in Diabetes
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidan
ce/DH_063081
The Year of Care website
http://www.dur.ac.uk/ccmd/yoc/
Department of Health (2002) National Service Framework for Diabetes: Delivery Strategy
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidan
ce/DH_4003246
Dept of Health (2006) Our health, our care, our say
http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Modernisation/
Ourhealthourcareoursay/index.htm
Jill Rodgers, Diabetes Health Education Specialist
Trudi Ackroyd, Project Manager Diabetes Year of Care, Calderdale & Kirklees CCG – Care
Planning SLA
15
PILOT LOCALLY COMMISSIONED SERVICE
SERVICE SPECIFICATION
Clinical triage for Point of Care Testing (POCT)
1. Introduction
This enhanced service specification details the specialised triage service to be provided by each GP
to support the implementation of the Point of Care Testing (POCT) for cardiovascular conditions. It
covers the clinical triage of specified cardiovascular conditions that can be diagnostically assessed
and treated in the community. The Service also covers the subsequent action needed following a
negative or positive test conducted by a Hub practice.
Initially two tests are being provided: D-Dimer for suspected DVT and BNP for suspected Heart
Failure. These form part of a wider programme that includes the use of Community Cardiology
Services for Heart Failure and for further assessment and treatment of DVT.
All GP practices are expected to sign up for the first part of the pathway and provide clinical triage
using a protocol and a screening tool. They will then refer suitable patients to a practice acting as a
test hub, and take subsequent action depending upon the results of the test. This local enhanced
service specifies both the triage and subsequent actions.
2. Aims
2.5
The overall aim of the programme is to serve the needs of GPs and their patients when a
patient presents with symptoms possibly indicative of certain cardiovascular conditions
(DVT, HF, etc) so that the patient is quickly placed on the appropriate treatment pathway or
are negatively assessed and either treated for an alternate condition or reassured.
2.6
The first specific aim of this POCT Service is to ensure that all GPs can provide consistent
triage so that a) acute cases are referred straight away, b) intermediate cases are tested in
the community prior to being given community treatment where indicated and c) an
alternative diagnosis is sought where indicated. Consistency is required to ensure that
clinical assessment efficacy supports the overall efficacy of the testing regime.
2.7
The second specific aim of this POCT Service is to ensure that GPs act in a consistent way
consequent on the results of the test and wherever possible safely maintaining the patient in
the community.
2.8
The overall measurable outcomes of the programme are:



A reduction in secondary care referrals for suspected DVT. Initially referrals will only
include probable DVT, and depending upon the results of a pilot of community
Doppler Testing, community treatment may also be initiated.
A reduction of secondary care referrals for suspected Heart Failure to only include
patients whose Heart failure indicates the need for secondary care intervention. All
other patients whose BNP is abnormal will be seen by community cardiology
services.
Inclusion of GPs in the register of training.
3. Background
16
This POCT Service forms part of an overall programme to maximally use Point of Care Testing and
treatment in the community for certain cardiovascular conditions where acute intervention is not
required.
The overall programme has the following components:
-
-
-
This POCT Service that enables all GPs to clinically triage for the conditions improving
efficacy of screening and supporting the patient with suitable medical management.
Several practices acting as Hubs (provided through the HUB Service) that support all GPs
by providing a near practice that has agreed to undertake tests as close to “on demand” as
practical and to ensure that all tests are conducted to a safe and consistent standard.
A Lead Practice (provided through Lead Practice Service) that sets the protocols, proformas
and scoring systems appropriate to each test, provides a service web address, training
material and training for Hubs and GPs, and supervision of audit through Hubs.
An arrangement for further tests to be piloted (normally by GPs that are part of the
Community Cardiovascular Services) and rolled out after careful evaluation.
Community Cardiovascular Services that provide relevant treatment and advice and
guidance to GPs.
The design of the process used is based on the prior experience of the 2009-2012 DVT Local
Enhanced Services, pilot on other tests and NICE guidance.
4. Service Outline
4.1
The service applies to patients with suspected DVT and Non-acute Heart Failure. The
service may be extended to other conditions. When extended, additional training will be
provided and required but the same Service Outline process will apply. Extension to other
conditions will only be based on efficacy demonstrated through an audit of a pilot and other
evidence, and following agreement by the commissioners.
4.2
Presentation: Applicable to patients for conditions where a protocol exists. The test may
ONLY be ordered when indicated by the triage screening protocol. The operation of the
protocol is achieved through the completion of a proforma which may also have embedded
an assessment instrument (eg Wells Score). The current version of the screening proforma
is available from www.mkcardiovascular.co.uk. In some cases the proforma will indicate
that the patient should be referred directly to acute care.
4.3
Common aspects of care: Where a GP decides that a test is indicated the appropriate
proforma will have been completed which will provide the clinical assessment details
associated with the test, including any risk scoring relevant at this stage. The patient shall
be given an information sheet about the test (how the test is conducted, reason for the test
and purpose of the test). Information sheets are available from
www.mkcardiovascular.co.uk. In some cases the proforma will indicate that the patient
should be referred directly to a Community Cardiovascular Service (for example suspected
HF with a history of MI)
The practice shall book the test with a HUB and arrange any follow-up in the practice with
the patient, or may refer the patient to the Community Cardiovascular Service taking into
account the level of urgency indicated on the proforma.
Each practice is either expected to be a Hub or have relationships with a Hub practice. The
test can be conducted in one of two ways: (preferred way) the patient is sent to the Hub, and
a copy of the proforma is forwarded to the Hub by NHS.NET e-mail, or (alternatively, for
example following a home visit) a venous sample is taken and the sample and proforma are
taken to the Hub. Current Hub operational status will be available from
www.mkcardiovascular.co.uk .
17
4.4
What the Hub does: acts according to the protocol and content of the proforma. Normally
a venous blood sample is taken and it is processed. (Exceptionally a venous blood sample
is supplied.) The sample processing time can take up to fifteen minutes.
If the patient is present they are asked to wait. If the test results are equivocal the patient
may be re-tested. Test results and re-testing are all recorded or attached to the proforma.
If test results coupled with proforma have a “Red Flag” status and the patient is present a
GP responsible for the Hub will initiate any “Red Flag” action and advise/discuss with the
referring GP. If the patient is not present the GP referrer for the Hub will be advised by the
Nurse or HCA conducting the test at the time, or if not possible by a GP responsible for the
Hub.
Where there are no “red flag” the result will be passed back to the referring GP for action
using NHS.NET e-mail.
The Hub will document and record the test and results including keeping a copy of the
proforma. This record keeping of the Hub will be used to organise payment of the referring
practice and used for audit and service development purposes.
4.5
Follow Up of the test results: beyond any “Red Flag” action the referring practice has
responsibility for all follow up actions. They must, in particular, have ensured that it is
possible to initiate a follow up action within the same day.
4.6
Appropriate training will be made available via the Lead Practice to each GP. Only GPs
with a record of appropriate training may request testing under the Service.
4.7
Record keeping: Practices should store copies of their proformas in their clinical record
system in the normal way. Read Codes will be provided as part of the training package.
Service information will be collected using HUB records.
5. Performance requirements
5.1
The Practice shall use the relevant latest proforma for the screening triage service.
5.2
The Practice shall ensure that the relevant follow up arrangements indicated by the protocol
are complied with after the test results have been made known.
5.3
The Practice shall, if required by the Commissioner, open its specific clinical records of
patients using the programme to an audit conducted by a suitable person.
6. Management and Governance
6.1
Training Responsibility – the Practice is responsible for ensuring that existing GPs and
new starters conducting triage screening assessments under this Service are adequately
trained and have been registered with the Lead Practice as having been trained.
6.2
It is the Practice responsibility to ensure training and competencies of clinicians delivering
this service are kept up to date.
6.3
Adverse and Critical Incidents: all incidents about the service including patient complaints
will be passed to the Lead Practice for investigation, the results of incident investigations will
be made available to all practices.
7. Dispute resolution
18
7.1
It is in the interest of both the Practice and the Commissioner for any disagreement to be
resolved locally, firstly by the Parties key managers and, in the event of any failing
agreement, the Commissioner’s dispute resolution shall be followed.
8. Termination of contract
8.1
Termination by agreement
8.1.1
The Commissioner and the Practice may mutually agree in writing to terminate the contract
and if the Parties so agree, they shall agree the date upon which termination shall take effect
and any further terms under which the contract shall be terminated.
8.2
Termination by notice
8.2.1
The Commissioner or the Practice may terminate this contract by serving three months
notice in writing.
9. Finance
9.8
Referring practices are not required to submit activity data: the records produced by a HUB
on attendance for a test are used to initiate payment to the Practice.
9.9
Payments will be made monthly to practices following acceptance of the data by the
commissioner. Acceptance does include reasonable checks that the data is accurate and
complete, and data may be returned to Hub Contractors for correction and re-submission.
9.10
Where the performance of the Practice does not meet the required standard set out in this
agreement, a deduction as agreed by both Parties may be made.
9.11
The sums payable by The Commissioner to the Practice for the provision of this service shall
be the contracted price. All other costs, charges, fees and expenses shall be the
responsibility of the provider.
9.12
A tariff of £25 will be paid to the Practice for screening clinical triage for each patient being
tested in a HUB.
9.13
Payments under this scheme are inclusive of all superannuation (both employers and
employees) and the Commissioner has no further liability.
10. Audit
10.1
MKCCG reserves the right to enter a practice and obtain access to relevant records to
undertake an audit of the enhanced service at any time. The objective of the audit would be
to ensure that this contract provides value for money to the CCG. The audit would check the
adequacy of controls, the integrity and reliability of information for billing in the area under
review. This is to ensure that payment is only made for valid work completed. The scope of
the audit does not include checks on the quality of activity. Practices would be given one
weeks notice of attendance and will be required to make the necessary records available.
Each auditor would have appropriate authority from the CCG, treat any records viewed with
confidentiality, and provide clear ID.
19
Locally Commissioned Service
Dyspepsia in Adults in Primary Care
Schedule 11
1st April 2014 – 31st March 2015
Background
Locally the demand for outpatient appointments for Upper Gastro Intestinal procedures is stretched.
This is further compounded by the introduction of the maximum 18 week
wait from GP referral to commencement of treatment in secondary care.
Annually 40% of the adult population may suffer from dyspepsia, although only about 2% consult
their GP. Currently, prescribed drugs and endoscopies alone actually cost the NHS about £600m,
and over the counter medication costs patients a further £100m.
The National Institute for Clinical Excellence (NICE) Clinical Guideline 17 (August 2004) provides
evidence-based recommendations for the primary care management of dyspepsia symptoms and
underlying causes in adults.
There are three main changes between current and previous NICE guidelines as follows:



management of symptoms in primary care, rather than routinely seeking a pathological
diagnosis, is appropriate for most patients
alarm signals and signs are the major determinant of the need for endoscopy, not age on its
own
long term care should emphasise patient empowerment, for example by promoting ‘on
demand’ use of the lowest effective dose of Proton Pump Inhibitor (PPI)
In most patients without alarm signs it is appropriate to manage symptoms without a formal
diagnosis. Endoscopy is used to investigate alarm signs and identify gastric and duodenal ulcers as
well as rare cases of oesophageal and gastric cancer. The important identification of the bacterium
Helicobacter pylori in 1983, with development of effective antibiotic treatment, has revolutionised
treatment for peptic ulcer disease.
Purpose of the Service
The purpose of this local enhanced service is to enable the provision of primary care management
of dyspepsia in Milton Keynes CCG for registered adult patients by general practitioners, practice
nurses, pharmacists and/or other primary healthcare professionals who have direct contact with
patients. Provision of primary care management of dyspepsia in adults should result in a reduction
in the number of patients referred to secondary care for assessment, diagnosis and/or treatment for
dyspepsia and should also result in more appropriate prescribing of drug therapies i.e. PPIs.
Service Outline
(i)
Presentation: At presentation to primary care, assessment should be undertaken of the
need to refer a patient either immediately or urgently for endoscopy. If presenting to
pharmacies, this referral should be via the general practitioner
(ii)
Common aspects of care should be offered to all patients, including access to education,
materials and advice about self-treatment, lifestyle (including weight
management
and
smoking cessation advice) and managing long term symptoms
(iii)
Where referral for endoscopy is not required patients should be treated, noting conditions
where endoscopic referral may become appropriate
20
(iv)
Helicobacter pylori testing and eradication should follow NICE guidelines.
(v)
C13-urea breath tests are recommended as the test of choice as these are more accurate
than serological tests, can be used pre and post treatment, and are more acceptable to
patients
(vi)
C13-urea breath test kits will be available from Typharm Group, Pylobactell kits on tel. no.
01603 735217 at a cost of £16.50 plus VAT each. Note the minimum order will be 10 kits
per practice and that postage is free. Each practice may order individually as required.
Please state when ordering that it is an order under CCG agreement. Note the costs for
these orders will be met for by the CCG, but audited against invoices as required.
(vii)
Appropriate training must be available to the primary care team to enable team
members to understand the problems experienced by adults with dyspepsia and to
communicate effectively with them. Training should include the assessment of symptoms,
carrying out C13-urea breath testing and interpretation of results, and managing follow up
treatment and/or referral for endoscopy
(viii)
Review. All providers of this service shall undertake annual patient review which must
include:
a)
b)
c)
d)
those patient identified as suffering from dyspepsia
those patients identified as suffering from dyspepsia who are referred immediately or
urgently for endoscopy
those patients identified as suffering from dyspepsia who are C13-urea breath tested
of those patients C13-urea breath tested:
(i)
(ii)
the numbers of negative results and details on ongoing
management; and
the numbers of positive results and details of ongoing management
Accreditation
All professionals providing this service who can satisfy at appraisal and revalidation that they have
such continuing experience, training and competence as is necessary to enable them to contract for
the enhanced service shall be deemed professionally qualified to do so.
References
“Which test for Helicobacter pylori in primary care?”, Drugs and Therapeutic Bulletin, Vol 42, No 8,
September 2004
Clinical Guideline 17 “Dyspepsia – Management of Dyspepsia in Adults in Primary Care”, National
Institute for Clinical Excellence, August 2004
Note
Practices working under this service will agree to follow the Dyspepsia pathways in the Map of
Medicine (copy of the pathway is attached Appendix 1) and not use other methods of H-Pylori
testing, and will not provide kits through prescriptions.
Finance & Costs
Each practice contracted to provide the dyspepsia pathway service will receive a £60.54 fee per
patient in 2014-15.
Monthly anonymised patient activity data produced from the clinical system detailing the following
will be submitted to the CCG electronically to [email protected] monthly, every
month in Microsoft Excel format only.
o
o
Patient ID Number (anonymised).
Read code.
21
o
o
Read code description.
Date treatment done.
Failure to send this information to the CCG will result in a nil payment.
Performance Monitoring
Practices will be responsible for reporting to the Department of Health and Milton Keynes CCG all
services given as soon as possible in accordance with the local arrangements.
As a minimum, practices will need to ensure they keep activity information that records the
interventions carried out at an individual anonymised patient level. Clear identification of the
practitioner who carried out the intervention needs recording.
Audit
MKCCG reserves the right to enter a practice and obtain access to relevant records to undertake an
audit of the enhanced service at any time. The objective of the audit would be to ensure that this
contract provides value for money to the CCG. The audit would check the adequacy of controls, the
integrity and reliability of information for billing in the area under review. This is to ensure that
payment is only made for valid work completed. The scope of the audit does not include checks on
the quality of activity. Practices would be given one weeks notice of attendance and will be required
to make the necessary records available. Each auditor would have appropriate authority from the
CCG, treat any records viewed with confidentiality, and provide clear ID.
Termination/Alteration
The provider will give at least 3 months notice of the intention to terminate this agreement. In
exceptional circumstances the CCG may agree to reduce this period.
The CCG will give at least 3 months notice of any intention to change or terminate this agreement
allowing for the fact that currently the service runs to 31st March 2015.
Service Specification for a Locally Commissioned Service – Dyspepsia
All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. The specification of this service is designed to cover the enhanced
aspects of clinical care of the patient, all of which are beyond the scope of essential services. No
part of the specification by commission, omission or implication defines or redefines essential
services.
22
Administration of Gonadorelin Analogues
(e.g. Goserelin, Leuprorelin Acetate and Triptorelin)
Specification for a Locally Commissioned Service
1st April 2014 – 31st March 2015
Aim
To support practices in continuing to administer Gonadorelin analogues where it is safe and
clinically appropriate to do so.
Service Outline
Administration of the drug is to be carried out by competent practitioners who have received
appropriate training. Practitioners may refuse to provide this service for individual patients where
they believe that it is not clinically appropriate or where there is no capacity within the practice for
administering the medicines.
Infection Control - Practitioners are responsible for the control of infection and infection control
policies, including handling of used instruments and disposal of clinical waste, must be in place.
Storage
Medicines will be stored as per manufacturers instructions, including appropriate fridge storage if
necessary.
Consent – In each case the patient should be fully informed of the treatment options and the
treatment proposed.
Performance Monitoring - Full records of each intervention should be maintained in such a way
that aggregated data, and details of individual patients, are readily accessible. This should apply
whether records are kept manually or electronically. Clear identification of the practitioner who
carried out the intervention should be recorded.
Untoward Events
It is a condition of participation in this service that practitioners will be given notification, in addition
to their statutory obligations, within 72 hours of the information becoming known to him/her, to the
CCG clinical governance lead of all emergency admissions or deaths of any patient covered under
this service, where such admission or death is or may be due to usage of the drug(s) in question or
attributable to the relevant underlying medical condition.
Accreditation
Those clinicians who had previously provided services similar to this enhanced service and who
satisfy at appraisal and revalidation that they have such continuing medical experience, training and
competence as is necessary to enable them to provide the enhanced service shall be deemed
professionally qualified to do so.
Finance
Per Administration
£15
Monthly anonymised patient activity data produced from the clinical system detailing the following
will be submitted to the CCG electronically to [email protected] monthly, every
month in Microsoft Excel format only.
o
o
o
o
Patient ID Number (anonymised).
Read code.
Read code description.
Date treatment done.
23
Failure to send this information to the CCG will result in a nil payment.
Audit
MKCCG reserves the right to enter a practice and obtain access to relevant records to undertake an
audit of the enhanced service at any time. The objective of the audit would be to ensure that this
contract provides value for money to the CCG. The audit would check the adequacy of controls, the
integrity and reliability of information for billing in the area under review. This is to ensure that
payment is only made for valid work completed. The scope of the audit does not include checks on
the quality of activity. Practices would be given one weeks notice of attendance and will be required
to make the necessary records available. Each auditor would have appropriate authority from the
CCG, treat any records viewed with confidentiality, and provide clear ID.
Termination/Alteration
The provider will give at least 3 months notice of the intention to terminate this agreement. In
exceptional circumstances the CCG may agree to reduce this period.
The CCG will give at least 3 months notice of any intention to change or terminate this agreement
allowing for the fact that currently the service runs to 31st March 2015.
Service Specification for a Locally Enhanced Service – Administration of Gonadorelin
analogues
All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. The specification of this service is designed to cover the enhanced
aspects of clinical care of the patient, all of which are beyond the scope of essential services. No
part of the specification by commission, omission or implication defines or redefines essential
services.
24
Insulin Services for Diabetes in Primary Care
Specification for a Locally Commissioned Service
1st April 2014 – 31st March 2015
Introduction
This service will enable some patients using insulin to be cared for within a community setting. A
practice providing this service must meet the required accreditation (p4) and must provide initiation
of insulin for people with Type 2 diabetes as well as ongoing care of people with Type 1 or Type 2
diabetes using insulin.
Practices may apply to provide this service as long as the following criteria are met:
 *The practice staff providing the service will be assessed by MK Diabetes Care before
signing up to and starting the service
 The practice must initiate at least 6 patients on insulin in the last year
 The service must have been audited by the MK Diabetes Care / GPwSI within the last 12
months and found to be delivering all aspects of the service specification in full.
 *See Accreditation criteria below
Background
People using insulin have traditionally been cared for in the hospital diabetes clinic. There are
increasing numbers of people with diabetes, and growing numbers of people with type 2 diabetes
mellitus using insulin. About 30% of the total diabetic population will be using insulin at any one time
(i.e. all type 1s and approx 15% of type 2s).
Some practices are already undertaking both the initiation of insulin in Type 2 Diabetes, and the
routine ongoing care of both people with Type 1 and Type 2 using insulin. The nGMS contract QoF
rewards practices for good data collection and reaching evidence based targets, but takes no
account of where a patient is receiving their care. A well organised practice can collect data from
patients who are being seen at the hospital diabetes clinic and score highly without undertaking any
of the actual care. The local enhanced service for insulin users will reward practices prepared to
improve their skills and undertake this work. It fits with the philosophy of NHS Milton Keynes,
pushing care out of the hospital setting, and increasing capacity for services in the community.
Aims




To provide a high quality community based insulin service for people with diabetes.
To enable more people with diabetes to be cared for solely within primary care
To improve patient satisfaction by providing continuity of care & a care planning approach
To reduce referrals to the hospital service.
Service Outline
This Service Specification details the criteria and the following pages contain some further guidance
from the CCG on expected processes, outcomes and deliverables based on this process.
The practice would be expected to be implementing the Care Planning approach prior to
starting LES Insulin.
Exclusion criteria will be:
 Children and young people up to age 18
 Renal patients
 People with complex complications
 People with diabetes who are using insulin pumps
 Women with gestational diabetes
25
Service to be provided
Development of a Register
An enhanced register of people (>17 years as per QOF)
with diabetes, which would demonstrate those using
insulin, where their care was received (hospital, GP or
shared), dates of annual and interim reviews, and any
diabetes related complications.
Clinical services for insulin
users
Conversion to insulin therapy of people with type 2
diabetes (READ code: 66AHO) who are not achieving
glycaemic control on oral hypoglycaemic agents,
including monitoring and follow-up as necessary for
individual patients.
Regular review (6 monthly minimum – READ code:
66AP), using the care planning approach, for people
with either type 1 or 2 diabetes who are using insulin.
This will include full clinical review, and education:
 HbA1c blood test
 Blood pressure
 Cholesterol & blood lipids
 Kidney tests
 Weight & BMI
 Smoking
 Comparison with previous tests if available
 In line with care planning patients to receive
results prior to their review appointment
 Review blood glucose records & hypoglycaemic
episodes
 Advice re dosing & switching types
 Check injection sites
 Discuss sharps disposal
 Discuss hyperglycaemia & sick day rules
 Discuss driving implications and hypos
 Ensure Insulin Passports in place
Individual care plans
Protected time
Call and Recall
Patient Education
A clear summary of care plan (agreed priorities and
goals, issues and concerns of the person with diabetes)
should be recorded and a copy given to the person with
diabetes.
The practice has a diabetes clinic set up which allows
protected time for both nurse and doctor consultation.
Insulin initiation would be expected to require an initial
appointment of 1hour and a follow-up appointment of at
least 30 minutes.
Review would be expected to require 30 minute
appointments.
Ideally 6 monthly systematic call and recall in place
Selection of written educational material available for
patients.
A variety of insulin pen devices available for
demonstration
Where initiating insulin in people with type 2 diabetes
there should be a comprehensive educational session
to include:
Diet
26
Professional Links
Blood glucose monitoring
Disposal of sharps following MK guideline
Use of insulin device and injection technique
Hypoglycaemia
Self adjustment of doses
Driving implications
Managing insulin when unwell
Insulin Passports
Work together with other professionals when
appropriate.
Establish close links with the Diabetes Specialist
Nurses MK Diabetes Care / Maple Unit
Referral Policies
Refer appropriately to:
 dieticians and podiatrist.
 MK retinal screening service.
Record Keeping
Audit
See audit
The practice will aspire to the nGMS Quality and
Outcomes Framework standards. A separate audit of
those using insulin to be performed annually, and
submitted to MK Diabetes Care.
The report would detail:
 how many people using insulin for whom the
practice had been solely responsible.
 in how many insulin had been initiated.
 The type of diabetes
 The last HbA1c for each patient using the
service
 an annual audit of people initiated on insulin by
the practice of HbA1c and weight and a
comparison of latest results with results at
initiation.
 The practice would be expected to meet with the
MK Diabetes Care Diabetes Specialist Nurse
and GPwSI annually as part of quality control
and to discuss their annual audit.
A practice taking on insulin services would be expected
to have gained additional expertise, as follows:
Prior to commencement of the service and ongoing:
 one lead GP and one practice nurse to have a
Warwick Certificate in diabetes care (or
equivalent) (Equivalence will be assessed by the
GPwSI and Consultant Diabetologists)
 one lead GP and one practice nurse to have
attended an insulin initiation study day / course
and have been assessed by MK Diabetes Care
in practice
Review
Accreditation
Exception to the above accreditation may be allowable
when:
1. the practice have been providing the
insulin initiation service under the terms
of the 1 April 2008-31 March 2009
SERVICE and therefore, either one lead
GP or one practice nurse has a Warwick
Certificate in diabetes care (or
27
equivalent) AND
2. The service must have been audited by
the GPwSI within the last 12 months and
found to be delivering all aspects of the
service specification in full.
Ongoing:
 Evidence of active involvement in care with
records of numbers of patients started on insulin
over previous 12 months, and numbers solely
under primary care.
 Annual educational update of at least one half
day.
 The practice will participate in the National
Diabetes Audit
Practices meeting the above criteria may apply to provide this service on behalf of and in agreement
with, another practice to their practice population.
Performance Monitoring
As a minimum, practices will need to ensure they keep activity information that records the
interventions carried out which is capable of being submitted to the CCG in an anonymised form.
Clear identification of the practitioner who carried out the intervention needs recording.
The practice will be expected to report activity levels monthly via the Enhanced Services return
form. This will include numbers of patients initiated on insulin and patients who are under the sole
care of the practice on insulin. A fuller more clinical audit should be produced annually and
discussed with the GPwSI and the Diabetes Specialist Nurse from MK Diabetes Care.
The practice will submit the following information to the CCG electronically to
[email protected] monthly, every month in Microsoft Excel format only:
o
o
o
o
Patient ID Number (anonymised).
Read code.
Read code description.
Date treatment done.
Failure to send this information to the CCG will result in a nil payment.
Untoward Events
The practice would be expected to report any adverse events involving service users to CCG Head
of Clinical Governance.
Payments
£207.35 per patient for initiation and subsequent care for one year.
Claims for payment should be made on the enhanced services monthly return form. The Read code
should be – Conversion to insulin: 66AHO
For year two and onwards the practice will be paid £51.84 per patient per full clinical review for sole
care of a patient using insulin. This is for a maximum of two reviews per year. Practices must not
claim for a review where care has been shared with the hospital outpatient clinic/intermediate
service within the previous 6 months.
28
Practices may claim for a review where care has recently transferred from the hospital outpatient
clinic/intermediate service; however claims should not be made if the patient is subsequently rereferred
Read codes used should identify the extra work undertaken as part of this enhanced service for
people with diabetes using insulin and not the normal routine work and reviews undertaken for
diabetes care.
Other read codes which might be used with reference to this service are:
 66AP. Diabetes: practice programme (sole care and maximum of two reviews per year)
 66AQ. Diabetes: shared care programme (practice and hospital)
 66AU. Diabetes care by hospital only
Audit
MKCCG reserves the right to enter a practice and obtain access to relevant records to undertake an
audit of the enhanced service at any time. The objective of the audit would be to ensure that this
contract provides value for money to the CCG. The audit would check the adequacy of controls, the
integrity and reliability of information for billing in the area under review. This is to ensure that
payment is only made for valid work completed. The scope of the audit does not include checks on
the quality of activity. Practices would be given one weeks notice of attendance and will be required
to make the necessary records available. Each auditor would have appropriate authority from the
CCG, treat any records viewed with confidentiality, and provide clear ID.
Notice
The provider will give at least 3 months notice of the intention to terminate this agreement. In
exceptional circumstances the CCG may agree to reduce this period.
The CCG will give at least 3 months of any intention to change or terminate this agreement in any
case currently the service runs to 31st March 2015.
Service Specification – Insulin Service
All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. This enhanced service specification outlines the more specialised
service to be provided in primary care for patients using insulin. The specification of this service is
designed to cover the enhanced aspects of clinical care of these patients which is beyond the scope
of essential services. No part of the specification by commission, omission or implication defines or
redefines essential or additional services
29
PILOT LOCALLY COMMISSIONED SERVICE CONTRACT
SERVICE SPECIFICATION
Lead Practice for POCT (Point of Care Testing)
1. Introduction
This enhanced service specification details the implementation of the Lead Practice for Point of
Care Testing (POCT) for cardiovascular conditions. It covers the Clinical Governance and
administrative responsibilities for the Lead Practice in supervising and developing the use of Point of
Care Testing (POCT) for cardiovascular conditions.
Initially two tests are being provided: D-Dimer for suspected DVT and BNP for suspected Heart
Failure. These form part of a wider programme that includes the use of Community Cardiology
Services for Heart Failure and for further assessment and treatment of DVT.
All GP practices are expected to sign up for the first part of the pathway (the POCT Service) and
provide clinical triage using a protocol and a screening tool. They will then refer suitable patients to
a limited number of practices acting as test hubs (the HUB Service).
2. Aims
2.9
The overall aim of the programme is to serve the needs of GPs and their patients when a
patient presents with symptoms possibly indicative of certain cardiovascular conditions
(DVT, HF, etc) so that the patient is quickly placed on the appropriate treatment pathway or
are negatively assessed and either treated for an alternate condition or reassured.
2.10
The primary aim of this Lead Practice Service is to ensure that Clinical Governance and
training is in place so that all tests are performed and supervised in a consistent and safe
way. Consistency is required to ensure that testing efficacy supports the overall efficacy of
the testing regime.
2.11
A secondary aim is for the Lead Practice to develop and promote further developments of
POCT for other conditions. This will be achieved through piloting of other test regimes and
service developments alongside the Community cardiovascular Services.
2.12
The overall measurable outcomes of the programme are:



A reduction in secondary care referrals for suspected DVT. Initially referrals will only
include probable DVT, and depending upon the results of a pilot of community
Doppler Testing, community treatment may also be initiated.
A reduction of secondary care referrals for suspected Heart Failure to only include
patients whose Heart failure indicates the need for secondary care intervention. All
other patients whose BNP is abnormal will be seen by community cardiology
services.
Inclusion of GPs and Hub GPs and staff in the register of training.
3. Background
This Lead Practice Service forms part of an overall programme to maximally use Point of Care
Testing and treatment in the community for certain cardiovascular conditions where acute
intervention is not required.
The overall programme has the following components:
30
-
-
-
This POCT Les that enables all GPs to clinically triage for the conditions improving efficacy
of screening and supporting the patient with suitable medical management.
Several practices acting as Hubs (provided through the HUB Service) that support all GPs
by providing a near practice that has agreed to undertake tests as close to “on demand” as
practical and to ensure that all tests are conducted to a safe and consistent standard.
A Lead Practice (provided through this Lead Practice Service) that sets the protocols,
proformas and scoring systems appropriate to each test, provides a service web address,
training material and training for Hubs and GPs, and supervision of audit through Hubs.
An arrangement for further tests to be piloted (normally by GPs that are part of the
Community Cardiovascular Services) and rolled out after careful evaluation.
Community Cardiovascular Services that provide relevant treatment and advice and
guidance to GPs.
The design of the process used is based on the prior experience of the 2009-2012 DVT Local
Enhanced Services, pilot on other tests and NICE guidance.
4. Service Outline
4.1
Personnel: The Lead Practice will identify to the Commissioner and to all practices the
individuals responsible for the following roles:




A Lead GP,
Alternative Lead GP,
Lead Nurse or Health Care Assistant
Administration Contact
4.2
Notification: Where there are changes in the individuals performing these roles, these will
be notified. Notification will be by e-mail to the Commissioner, the Commissioner’s
Cardiovascular Project Manager and all practice managers, all GPs and all practice
nurses.
4.3
Provision of Training - HUBs: The Lead Practice will provide training and advice to GPs,
nurses and Health Care Assistants in practices signing up to the local POCT HUB service,
according to demand. All courses will cover aspects of administration and record keeping:
therefore, other practice staff may attend either type of course. The training may be by
shadowing the operation of Hub in the lead practice.
Trained personnel will be provided with certificates of training and competence.
4.4
Provision of Training - GPs: The Lead Practice will provide training and advice to GPs, in
practices signing up to the local enhanced service. Up to 3 training courses will be provided
for GPs at lunchtimes, according to need.
All courses will cover all aspects of test and other clinical assessment, the use of protocols
and scoring systems and the appropriate record keeping and “Read” coding. Attendees will
be provided with certificates of attendance.
4.4
Training Register: A register will be kept by the Lead Practice of training and trainees.
4.5
Monitoring:
The Lead Practice will advise the commissioners where performance is inadequate,
undesirably variable, and highlight good practice which can be extended.
Quarterly: The lead practice will review quarterly activity reports provided by the Hub
Practices with the Commissioners and the CHD lead.
31
Annually: The lead practice will use the quarterly activity reviews as a basis for an annual
audit meeting with Hub Practices.
4.6
Adverse and Critical Incidents: All incidents including complaints identified by any spoke
or hub provider will be reported, logged and investigated by the Lead Practice. The report
and investigation will be placed on (www.mkcardiovascular.co.uk) If the incident involves
the “Lead Practice” they will invite the Commissioner’s involvement in the investigation. The
commissioner may appoint any appropriate person (for example the CHD lead) to be
involved.
4.7
Point of Care Equipment: The Lead Practice will support the use of the Point of Care
equipment by:



Providing clinical advice to the CCG on which POC equipment to use, source of test
strips and other consumables, and the provision of independent calibration and
assay services
Holding spare equipment to cover emergencies
Liaising with any centralised procurement service or providers for equipment, test
strips, calibration and assay and HUBs to support the effective and common
management of equipment and consumables.
4.8
Clinical Meeting: The lead practice will organise an annual clinical audit meeting of HUBs.
Relevant representatives from MKHFT responsible for related services will be invited. The
meeting will also include discussion on adverse and critical incidents.
4.9
Provision of Patient Information: The Lead Practice will source the patient education
material to implement the POCT LES. “All patients shall be given access to education
materials and advice about self-treatment, and lifestyle and managing long term symptoms.”
4.10
Information Web-site Pages: the Lead Practice will maintain information web-pages
relevant to the screening and testing services provided through the POCT Lead Practice
Service, the POCT HUB Service and the POCT Service. These pages will allow the down
loading of assessment and reporting forms and protocols and patient information. They will
contain training information packs, the adverse and critical incident log and reports, audit
reports and findings and other related reference information and links, for example to NICE
or other guidance and publications. They will also show on the First page the current active
status of HUB practices and their contact information (Relevant Personnel, telephone
numbers and e-mail addresses including the practice’s NHS.NET e-mail for patient
information communications.) The web-site will also provide access to the training register.
4.11
Participation in Further Development: the Lead Practice will ensure they continue to
maintain their professional knowledge of the area covered by this Service. They will commit
to be available to undertake or support separately funded projects to pilot the use of similar
and further testing.
4.12
Provision of Specific Advice: the Lead Practice will ensure that they can be contacted for
advice by GPs and Hub Practices on any issues related to the testing regimes.
5. Performance requirements
5.1
The Lead Practice must also operate under the POCT Hub Service, with a higher level of
availability of at least 240 days (>95% availability).
5.2
The Lead Practice is accountable to the Commissioners for the extent to which the Service
Aims (2, above) are met. The Commissioners will meet with the Lead Practice, as required
32
and agree any necessary and reasonable corrective action to cover a failure of uptake,
access, training, safety, governance or other matter contained within this agreement.
5.3
The Commissioners may terminate the agreement if corrective action is not performed within
an agreed timescale.
6. Management and Governance
6.1
The Practice is responsible for ensuring that the Lead GP and Alternative Lead GP have the
necessary clinical expertise and training for the roles that they are undertaking. An
acceptable standard is certified GPs with Special Interest in Cardiology. But other
experience based standards may be demonstrated and agreed by the commissioner.
6.2
The Practice is responsible for ensuring that training and the competency of the clinicians
and administrative personnel, providing the service, are kept up to date.
7. Dispute resolution
7.1
It is in the interest of both the Practice and the Commissioner for any disagreement to be
resolved locally, firstly by the Parties key managers and, in the event of any failing
agreement, the Commissioner’s dispute resolution shall be followed.
8. Termination of contract
8.1 Termination by agreement
8.1.1
The Commissioner and the Practice may mutually agree in writing to terminate the contract
and if the Parties so agree, they shall agree the date upon which termination shall take effect
and any further terms under which the contract shall be terminated.
8.2 Termination by notice
8.2.1
The Commissioner or the Practice may terminate this contract by serving three months
notice in writing.
8.3 Termination through performance
8.3.1
The Commissioners may terminate this agreement with one month’s notice for a failure of
performance.
8.4
Record keeping on notice
8.4.1
Where the service is terminated earlier than the term of this agreement, the Lead Practice
will meet any requests from the Commissioner to supply records so that a new Lead Practice
can be appointed.
9. Finance
9.14
Where the performance of the Practice does not meet the required standard set out in this
agreement, a deduction as agreed by both Parties may be made.
9.15
The sums payable by The Commissioner to the Practice for the provision of this service shall
be the contracted price. All other costs, charges, fees and expenses shall be the
responsibility of the provider.
9.16
The Practice shall be paid a retainer of £2,785 per annum. Payment will be made quarterly
in advance following receipt of valid invoice.
33
9.17
The Practice will have use of a budget of up to £3,000 to cover the expenses of the annual
audit meeting and training meetings. This will include the Hub Practice contributions to
expenses of £125 per GP attending the audit meetings. Any increase in budget because of
an increase in Hub Practices will need to be discussed with the Commissioner in advance.
9.18
Payments under this scheme are inclusive of all superannuation (both employers and
employees) and the Commissioner has no further liability.
10. Audit
10.1
MKCCG reserves the right to enter a practice and obtain access to relevant records to
undertake an audit of the enhanced service at any time. The objective of the audit would be
to ensure that this contract provides value for money to the CCG. The audit would check the
adequacy of controls, the integrity and reliability of information for billing in the area under
review. This is to ensure that payment is only made for valid work completed. The scope of
the audit does not include checks on the quality of activity. Practices would be given one
weeks notice of attendance and will be required to make the necessary records available.
Each auditor would have appropriate authority from the CG, treat any records viewed with
confidentiality, and provide clear ID.
34
Minor Injuries (Comprehensive) Service Specification
01 April 2014 – 31 March 2015
Part 1: Introduction
1.1
Parties to the contract and contract duration
1.1.1 This service specification supersedes all previous correspondence from the PCT /
MKCCG.
1.1.2 NHS Milton Keynes CCG wishes to secure the provision of local enhanced primary
care services to patients by General Practices within Milton Keynes who wish to
provide such services. All GP Practices in Milton Keynes are eligible for this Service.
There must be a named GP lead for each practice wishing to deliver this service.
1.1.3 This Service will be offered from 1st April 2014 to 31st March 2015. Service
provision will be reviewed at the end of this period to determine if the service should
continue.
1.2
Vision
1.2.1 This specification sets out a model for a Minor Injury Service in Primary Care.
1.2.2 Utilisation patterns for A&E in the CCG area have been built up over many years and
are multi-factorial in origin. The Minor Injuries Service represents a significant
opportunity to build a sustainable shift in utilisation patterns, with a view to supporting
Primary Care to deliver care closer to home for patients. The associated Primary
Care 'CQUINs' are designed to foster collaboration within Primary Care and to allow
sustainable and justifiable investment within Primary Care. It is hoped that Primary
Care will view the Service and its associated Primary Care 'CQUINs' as an
opportunity to make a step-change shift in the approach to urgent care delivery that
could lead to even larger shifts in care delivery in the future. The Service and
associated Primary Care 'CQUINs' are also designed to reward good practice.
1.2.3 When looking at a potential shift of care from A&E to Primary Care several principles
need to be adhered to:
a) The quality of the service should remain the same or improve
b) There should be additional benefits to the patient, such as closer proximity
to services.
c) The transfer of services needs to be sustainable from both a provider point
of view (ie sufficient investment in the service to allow both short term delivery
and longer term investment) and from a commissioners view point ( i.e. the
service needs to represent a genuine shift of care from one location to
another).
35
1.2.4 It is proposed that a two tier approach is taken; firstly all practices will be offered the
Minor Injuries Service at a rate of £30. All practices will also be offered a Practice
'CQUIN' at a rate of £10.00 to achieve a target for repatriation of patients by care
delivery and support closer to home will be 20%. This is designed to focus on
delivering treatment within Primary Care to a greater proportion of urgent cases (of
those amenable to treatment in Primary Care) compared with the existing and
predicted ratios of treatment across Primary Care : Urgent Care : A&E.
1.2.5 The proposal is for a fixed Service and Primary Care ‘CQUIN’ at a fixed sum on top
once the appropriate care outcomes are achieved at practice level. Practices will
increase their financial opportunity if they achieve their target. This is based on
paying a total fee : Service £30.00 rate plus CQUIN of £10 = Total £40.00.
1.2.6 If providers do not achieve the 20% reduction, only £30.00 will be payable per case
thereby mitigating some of the cost impact for the CCG whilst still enabling an
appropriate level of income for Practices.
1.2.7 In view of the potential efficiency opportunity and to allow room for service
development and improvements it is therefore proposed that the targets for
repatriation of patients by care delivery and support closer to home will be 20% as a
lower figure, though some practices may achieve significantly more than this over
time. To achieve a 20% reduction Practices will need to repatriate up to 4.2 Patients
per day (based on the highest utilisation of A&E and MKUCS).
1.3 Monitoring and Review
1.3.1 Review of capability to deliver the service will be proportionate - i.e. it will be
expected that if asked the individual practitioner and the practice will be able to
provide documentary evidence of suitable CPD and it will be expected that it will also
be documented and discussed as part of appraisal and revalidation. Suggested
supportive audits will be provided by the CCG to guide practitioners on appropriate
and proportionate governance; again these or justifiable alternatives will need to be
made available if requested; as part of agreeing to the Service and Primary Care
'CQUINs' practitioners will be required to declare their adherence to these standards.
1.3.2 Primary Care 'CQUINs' will be based upon the model used in secondary care though differing in one main aspect - in that the CQUIN component will be a
significant proportion of the payment opportunity for a specific service rather than
36
aligned to overall payments. In addition these are locally negotiated approaches
within MK CCG. Further general guidance on CQUINS can be found here
http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
1.4 Service Aims
1.4.1 This service will be commissioned in the context of reforming emergency care
services and reducing demand on the A & E department.
1.4.2 This service aims to reduce activity in Accident and Emergency and the Urgent Care
Service by up to 50%. There is a expectation based on national and local evidence
that practices should aim to achieve 20%-30 % repatriation as a minimum.
1.4.3 This service recognises the need for a consistent approach to rewarding providers
equitably for providing Minor Injury services within their own or federated premises.
1.4.4 Professional consensus indicates that injuries and wounds over 48 hours old should
usually be dealt with through normal primary care services, as should any lesions of
a non-traumatic origin. By definition such cases are usually the self-presenting
“walking wounded”.
1.5 Service Model
1.5.1 The opportunity for Primary Care practitioners to optimise the financial and qualitative
benefits will increase in relation to their ability to provide an efficient service which is
responsive to patient demand. Therefore GP practices should configure themselves
either as:
A. Individual practices to deliver the necessary skill mix and managerial
oversight and capacity
Or as
B. Primary Care Federations, in order to maximise efficiencies, make best use
of facilities and deliver the necessary skill mix, managerial oversight and
capacity.
1.5.2 By incentivising this Service it is the intention of the commissioners to enable
practices to invest in the service including the provision of appropriately skilled staff
and publicity for patients, public and all stakeholders. In order to support this CCG
will provide a communications tool kit that will be aligned to the Choose Well
Campaign.
37
Part 2: Service to be provided
2.1 Service Outline
2.1.1 The following list gives guidance on the types of injuries and circumstances that lead
to the use of minor injury services and is not comprehensive:
1) lacerations capable of closure by simple techniques (stripping, gluing,
suturing)
2) significant soft tissue injury
3) minor dislocations of phalanges
4) foreign bodies
5) non-penetrating superficial ocular foreign bodies
6) following advice to attend specifically given by a general practitioner
7) following recent injury of a severity not amenable to simple domestic first
aid
8) following recent injury where it is suspected stitches may be required
9) following blows to the head where there has been no loss of consciousness
10) recent eye injury
11) Partial thickness thermal burns or scalds involving broken skin
a. which are not extensive
b. not involving areas of the body that may cause concern or may
benefit from more specialist treatment
12) foreign bodies superficially embedded in tissue
13) minor trauma to hands, limbs or feet
14) Whiplash giving cause for concern and requiring face to face consultation
15) Bruising giving cause for concern and requiring face to face consultation
Exceptions to this list (1-15 above) can be agreed with commissioners where the
practice does not intend to offer a specific treatment.
2.1.2 This Service will fund:
1) initial triage including immediately necessary clinical action to staunch
haemorrhage and prevent further exacerbation of the injury
2) history taking, relevant clinical examination, documentation
3) wound assessment to ascertain suitability for locally based treatment and
immediate wound dressing where indicated
4) appropriate and timely referral and/or follow up arrangements
5) adequate facilities including premises and equipment as are necessary to
enable the proper provision of minor injury services including facilities for
cardiopulmonary resuscitation
38
6) Health Care Professionals to provide care and support to patients
undergoing minor injury services
7) maintenance of infection control standards
8) information to patients on the treatment options and the treatment
proposed. The patient should give consent for the procedure to be carried
out and be recorded in the patient’s lifelong medical record.
9) maintenance of records for all procedures including the supply of a referral
letter to A&E. Patient to take the referral letter with them to the hospital.
2.1.3 Patients in the following categories are not appropriate for treatment by the minor
injury service. However, the enhanced service covers the appropriate referral of
these patients elsewhere:
1) 999 call (unless attending crew make prior arrangement with the GP
practice.)
2) any patient who cannot be discharged home after treatment
3) any patient with airway, breathing, circulatory or neurological
compromise
4) actual or suspected overdose
5) accidental ingestion, poisoning, fume or smoke inhalation
6) blows to the head with loss of consciousness or extremes of age
7) penetrating eye injury
8) chemical, biological or radioactive contamination injured patients
9) full thickness burns
10) burns caused by electric shock
11) : Partial thickness thermal burns or scalds involving broken skin
a. which are extensive
b. involving areas of the body that may cause concern or may
benefit from more specialist treatment injuries e.g. organs of
special sense
12) new or unexpected bleeding from any body orifice if profuse
13) foreign bodies impacted in bodily orifices, especially in children
14) foreign bodies deeply embedded in tissues
15) trauma to hands, limbs or feet substantially affecting function
16) penetrating injuries to the head, torso, abdomen
17) lacerating/penetrating injuries involving nerve, artery or tendon damage.
39
2.2 Accreditation/Competencies/Continuing Professional Development and Clinical
Leadership
2.2.1 Health Care Professionals providing clinical leadership and delivering the minor injury
services will be expected to:
a. have either current experience of the provision of minor injury work, or
b. have current minor surgery experience, or
c. have recent accident and emergency experience, or
d. have equivalent training which satisfies relevant appraisal and revalidation
procedures.
2.2.2 Health Care Professionals carrying out minor injury services must be competent in
resuscitation and, as for other areas of clinical practice, have a responsibility for
ensuring that their skills are regularly updated. Doctors carrying out minor injury
activity should demonstrate a continuing sustained level of activity, conduct regular
audits of data and take part in appropriate educational activities.
2.2.3 Health Care Professionals delivering minor injury procedures should be appropriately
trained and competent taking into consideration their professional accountability and
the Nursing and Midwifery Council (NMC) guidelines on the scope of professional
practice.
2.2.4 The provider is required to maintain evidence of continuing professional development
in relation to this service. This may be required to be produced as evidence for reaccreditation. Clinical updates/training could include supervised practice,
liaison/clinical audit sessions or attendance at appropriate postgraduate
meetings/lectures/events etc.
2.3 Contractor services to include:
2.3.1 Offer treatment shown in the table in clause 2.4 to patients brought to the GP
Practice by ambulance. Attending ambulance personnel will triage the patient
problem and where appropriate take the patient to the nearest GP Practice for
treatment. This will not come into force until all parties are agreed to the
protocols, which are still under discussion.
2.3.2.Initial triage including immediately necessary clinical action to staunch haemorrhage
and prevent further exacerbation of the injury.
2.3.3.History taking, relevant clinical examination, documentation.
40
2.3.4.Wound assessment to ascertain suitability for locally based treatment and immediate
wound dressing where indicated.
2.3.5 Appropriate and timely referral and/or follow up arrangements.
2.3.6 Adequate facilities including premises and equipment as are necessary to enable the
proper provision of minor injury services including facilities for cardiopulmonary
resuscitation.
2.3.7 Healthcare professionals to provide care and support to patients undergoing minor
injury services.
2.3.8 Maintenance of infection control standards.
2.3.9 Information to patients on the treatment options and the treatment proposed.
2.3.10 Maintenance of records of all procedures including the supply of a patient referral
letter to A&E. Patient to take referral letter to A&E.
2.3.11 Where treatment is identified as requiring an X-Ray e.g. suspected fracture then the
GP must complete an X-Ray form and instruct the patient to take it with them to the
hospital.
2.3.12 The patient needs to present at the GP Practice to attract fee for item payment.
2.4 Evidence and Read Codes
2..4.1 A consultation for minor injury will be defined as:An injury that presents within 48 hours of occurrence and where there is evidence of
diagnosis and treatment in the patient records.
Read
Description
Code
9Na1
Consultation for minor injury
(The term ‘Consultation for minor injury’ coded 9Na1 must be added to the patient’s
record if the above criteria is met and submitted to the CCG as part of the monthly
claim process).
41
2.4.2 The Contractor must also record the following information in the patient record and
submit to the CCG on a monthly basis.
Read
Description
Code
9N58
Patient initiated encounter (PIE) – Emergency
Appointment
8HC1.
Refer to Accident & Emergency Department
(A&E)
Definition of Patient Initiated Encounter / Walk-in
 No appointment given
 No expectation that the patient was coming to the GP Practice
2.4.3 The following table outlines the Minor Injury procedures covered by this Contract and
for which treatments have been completed. It includes examples of the type of
evidence expected in the patient records with suggested read codes.
Correlation of CTV3 codes and Read V2 codes for Minor Injury Service
READ V2
Code
9Na1.
9N58.
8HC1.
S8z-3
READ V2 Term
Consultation for
minor injury
Patient initiated
encounter (PIE) –
Emergency
Appointment
Refer to Accident &
Emergency
Department (A&E)
Laceration
S8% would give "Open wound
of head, neck and trunk"
S9% would give "Open wound
of upper limb"
SA% would give "Open wound
of lower limb"
S8z.. is "Open wound of head,
neck and trunk NOS"
There is no code S8z-3, but it
could mean a range.
8BC7.
Glueing of wound
8BC8.
Application of
adhesive skin
CTV3
Code
XaJme
9N58.
CTV3 Term
Consultation for
minor injury
Appointment –
Emergency
Appointment
8HC1.
Refer to Accident &
Emergency
Department (A&E)
Both the following cover all
body parts:
Xa2N3 Open wound of
body region
XM0vr
Laceration of skin
Both are covered by:
XA013
Deep wound
Xa2dS
Glueing of wound
Ua1Cs
Application of
adhesive skin
42
closure
closure
7G2D5
Other skin toilet Cleaning of skin
wound NEC
XaEY1
7G214
Suture of skin NOS
XaKK2
7G245
Removal of foreign
body from skin NEC
7G245
Removal of foreign
body from skin NEC
XaEY1
72432
Removal of foreign
body from
conjunctiva
Removal of foreign
body from eye NEC
Minor head injury
72432
Removal of foreign
body from
conjunctiva
Removal of foreign
body from eye NEC
Minor head injury
XaEY2
Head injury advice
given
Burn - unspecified
XaIwl
72743
S6460
8CAP.
SH9%
XE0BV
XM0vo
SH9..
Toilet of skinCleaning wound Cleaning of skin
wound NEC
Suture of skin NOS
Xa485
Burn of skin of body
region
81H2.
Dressing of burn
SD8%
Superficial injury of
eye and adnexa
[V]Examination of
eyes and vision
O/E - fluorescein
staining NAD
O/E - fluoresceincorneal abr.
O/E - visual acuity
R-eye
O/E - visual acuity
L-eye
Slit lamp
examination
Sprains and strains
of joints and
adjacent muscles
Whiplash injury
SD8..
Superficial injury of
eye and adnexa
[V]Examination of
eyes and vision
O/E - fluorescein
staining NAD
O/E - fluoresceincorneal abr.
O/E - visual acuity
R-eye
O/E - visual acuity
L-eye
Slit lamp
examination
Sprains and strains
of joints and
adjacent muscles
Whiplash injury
Contusion (bruise)
with intact skin
Not an easy correlation. Try,
under Injury of skin:
XE2bL
Superficial bruising
2BH1.
2BH2.
2B6..
2B7..
312A.
S5%
S5704
SE%
ZV720
2BH1.
2BH2.
2B6..
2B7..
312A.
S5...
Xa06Y
Ua1Cp
which
includes
Xa3qW
Toilet of
skinCleaning
wound
Wound
cleaning
NOS
Cleaning
of skin
wound
NEC
Cleaning of
skin wound of
head or neck
Head injury advice
given
Burn - unspecified
The correct code for Burns is
SH%, which covers SH9 plus all
body parts
81H2.
Dressing of burn
ZV720
Also
relevant :
This covers all body
parts
Alternatively known as
Haematoma with intact skin
(% Means there will be codes under this level which may be more specific.)
2.4.4 The comprehensive nature of this contract means that laceration and removal of
foreign body are injuries where there is an expectation that the GP Practice performs
43
treatment at the surgery and does not refer to A&E unless the severity of the injury
falls under Part 4 of this contract.
Part 3: SERVICE PERFORMANCE AND QUALITY MEASURES
3.1 Statutory Compliance
3.1.1 The provider will exercise all reasonable skill, care and diligence in the performance
of the services. In providing the services set out, the provider will comply with all
applicable statutory and other legal requirements and regulations, all relevant
voluntary and compulsory codes of conduct, all relevant professional standards and
all applicable National Health Service directives, guidelines and codes. NHS Milton
Keynes CCG shall at all times have the right to inspect and monitor compliance with
all aspects of this agreement by the provider.
3.1.2 Safeguarding Children and Adults
The provider will comply with Independent Safeguarding Authority registration
requirements and appropriate level Criminal Records Bureau (CRB) Checks will be
undertaken for all staff
3.1.3 All health professionals have an essential part to play in ensuring that children and
families receive the care, support and services they need in order to safeguard
children and promote their health and development. The particular roles and
responsibilities of health professionals for child protection are set out in the HM
Government’s inter-agency child protection statutory guidance Working Together to
Safeguard Children (2010) and the service provider must ensure compliance with this
guidance.
3.1.4 The Service Provider will adhere to the Milton Keynes Safeguarding Children Board
Inter-Agency Policy and Procedures to Safeguard and Promote the Welfare of
Children and the NHS MK CCG Safeguarding Children Policy. These policies and
procedures must be available to all staff and the Service Provider is required to give
assurance to the commissioners on compliance with their safeguarding requirements
and any jointly agreed local policies.
Staff to attend safeguarding children training in accordance with local policy
3.1.5 All health professionals have an essential part to play in ensuring that Vulnerable
Adults including people who have a learning disability receive the care, support and
services they need in order to safeguard vulnerable adults and promote their health
and development. The service provider will have a policy which works
44
in accordance with current statutory guidance including the Mental Capacity Acct
2005, NHS Milton Keynes CCG Safeguarding Vulnerable Adults Policy and
Procedures.
3.1.6 Staff to attend safeguarding vulnerable adults training and Mental Capacity Act 2005
training in accordance with local policy
3.2.1 Infection Control
3.2.3 The provider will have access and adhere to national and local guidance in relation to
infection prevention and control principles and protocols.
3.2.4 The provider will ensure that up to date infection prevention and control policies are
written, reviewed and adhered to by all staff.
3.2.5 The environment must be clean, clutter free and sterile items stored appropriately i.e.
not on the floor. A cleaning schedule will be in place and monitored by the provider.
3.2.6 All clinical staff will adhere to standard precautions. Personal protective equipment
must be available and clinical staff to don appropriate personal protective equipment
in accordance with national guidance.
3.2.7 Staff must attend infection prevention and control training annually. Training manual
to be available.
3.2.8 An infection prevention and control audit or a self assessment will be undertaken by
the provider annually. This will be disseminated to the Infection Control Lead at the
CCG.
3.2.9 Sharps will be stored, handled and disposed of at the point of source in accordance
with national guidance. This process will be monitored by the provider.
3.2.10 All needlestick injuries will be treated as a significant event and will be investigated
by the provider. The report will be disseminated to the Infection Control Lead at the
CCG.
3.3.1 Premises and Equipment
3.3.2 The provider will ensure that the premises used for the provision of the service are:
a. suitable for the delivery of those services; and
b. sufficient to meet the reasonable needs of the patients.
3.3.3 The provider shall provide all of the required clinical equipment. This equipment shall
be maintained in accordance with manufacturers’ guidance and best practice and,
where appropriate, recalibrated annually.
3.3.4 Where the provider does not have capacity to deliver the service within their own
premises, this Service allows for the provider to federate with other local GP
practices in respect of delivering a Minor Injuries service to their registered patients.
45
3.4.1 Business Continuity
3.4.2 The provider must ensure that adequate arrangements are in place for continuity of
the service in the event of staffing shortages, facilities and system failures
appropriate to the service.
3.5.1 Record Keeping and Information Requirements
3.5.2 The provider should obtain consent to the procedure before it is carried out (where
an individual consents on a patient’s behalf, the person’s relationship to the patient
must be recorded).
3.5.3 The provider should take all reasonable steps to ensure that the consent is recorded
on the patients clinical record.
3.5.4 All providers of NHS commissioned care should use the latest NHS Information
Governance Toolkit to assist in implementation and assessment of compliance with
policy and legal requirements.
3.6.1 Significant Events
3.6.2 The Department of Health emphasizes the importance of collected incidents
nationally to ensure that lessons are learned across the NHS. A proactive approach
to the prevention of recurrence is fundamental to making improvements in patient
safety.
3.6.3 The provider must have systems in place for documenting and learning from
significant events, including reporting to the CCG, as appropriate.
3.6.4 The provider should be aware of and implement appropriately, the various reporting
systems, such as:
a. the National Patient Safety Agency National Reporting and Learning
System
b. the Medicines and Healthcare Products Regulatory Agency reporting
systems for adverse reactions to medication (yellow card system) and
accidents involving medical devices
c. the legal obligation to report certain incidents to the Health and Safety
Executive under the Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations (RIDDOR).
3.6.5 In addition to their statutory obligations, the provider should give notification, within
72 hours of the information becoming known to him/her, of all emergency
admissions or deaths of any patient treated by the provider under this enhanced
service, where such admission or death is, or may be due, to the providers treatment
of the relevant underlying medical condition covered by this specification.
46
3.7.1 Monitoring, Reporting and Submission of Claims
3.7.2 The provider must supply the CCG with such information as it may reasonably
request for the purposes of monitoring the provider’s performance of its obligations
under this service level agreement.
3.7.3 The provider is required to submit a claim to NHS Milton Keynes Clinical
Commissioning Group on a monthly basis for the number of patients receiving Minor
Injuries treatment. Claims submitted by the end of the month will be paid in the
following calendar month. Any claims submitted after the last day of the month will
not be paid until the calendar month following the date on which the claim was
submitted e.g. a claim submitted on the 2nd May in respect of a procedure
undertaken on the 30th April will not be paid until June. Any claims submitted after
the 30th June in respect of the previous financial year will not be accepted.
3.7.4 All claims should be recorded on the clinical system with the following Read Codes
and anonymised patient activity data produced from the clinical system detailing the
following will be submitted to the CCG electronically monthly. (see also section 2.4 of
this document for detail).

9Na1 Consultation for Minor Injury
A typical monthly claim will consist of some or all of the following elements as
appropriate:
Date of Treatment + Anonymised Patient ID Number + Consultation for Minor
Injury (Read Code) + Activity (Read Code) + Walk-In (Read Code) + Refer to
A&E (Read Code)
e.g 1234 + 9Na1 + 8BC7. + 9N58 + 8HC1.
The Walk-in (9N58) and Refer to A&E (8HC1) codes may not apply in all cases but
where they do apply the Contractor must record and submit them with each monthly
claim.
Failure to send this information to the CCG will result in a nil payment.
CQUIN data will be based upon SUS returns.
3.7.5 Invoicing and payments will be made on a monthly basis for the service component,
and quarterly in arrears one month after delivery of that quarters SUS data. The
quarterly payments will represent 60% of the total payment with a final balancing
payment due in line with the NHS financial year.
3.7.6 Pricing
3.7.7 All participating practices will receive a rate of £30.00 per case.
47
3.7.8 In addition to 3.7.7 above, all participating practices will receive a practice
'CQUIN' at a rate of £10.00 per case when a target level of 20%
reduction in A & E and MKUCS activity is achieved.(*see also 3.9.4
below).
3.7.9 The provider will receive a payment of £30.00 for each procedure undertaken by
clinical staff regardless of whether that is an accredited GP or Nurse.
3.7.10 The above payment is to cover:
a. staff time involved in undertaking the procedure
b. disposables/consumables associated with undertaking the procedure
c. all sterilisation/maintenance/calibration/servicing of equipment.
d. follow up appointment when required
3.7.11 No payment will be made in respect of procedures undertaken by staff not directly
employed by the provider.
3.8.1 Post Payment Verification
3.8.2 In accordance with the requirements of section 30 of its Standing Financial
Instructions, the CCG reserves the right to undertake validation of claims to ensure
that rules have been correctly and consistently applied and payments have been
claimed in accordance with the terms of this agreement.
3.9.1 Primary Care CQUIN
3.9.2 The process of the CQUIN has already been described. The CQUIN will be aimed at
ensuring all those individuals that can safely and appropriately be treated closer to
home by Primary Care are treated accordingly. An audit within NHS MK CCG has
shown figures in excess of 36% of attendees at A&E could have been treated in
other environments. Studies across the years have shown figures of A&E attendees
being treatable by services other than A&E as high as 80% in one case, though
figures of 25% to over 40% were commoner (PwC Attendance Exercise 2006 and
Literature review). NHS MK CCG A&E utilisation has been shown repeatedly to be
above national expected levels, and given the correlation with internal audits it is
proposed that the range of treatment in other environments is likely to be in the 3040% range, though with extra skills and capabilities higher figures could be safely
deliverable to the benefit of patients.
3.9.3 In view of the potential outlined above and to allow room for service development and
improvements it is therefore proposed that the targets for repatriation of patients by
care delivery and support closer to home will be 20% (as a lower figure).This will be
48
backed up by audits of case-mix and appropriateness at the A&E / UCC and Primary
Care delivery points.
3.9.4 Expected utilisation of A&E is a complex, multi-factorial process, therefore practices
will be base-lined according to their expected utilisation, based upon practice list
size, composition of patient morbidities, deprivation, geography and other relevant
factors. This will be mapped against CCG current utilisation and the impact of
treating patients closer to home will be overlaid to create a target outcome measure,
using the anticipated outcomes detailed above. Practices will then be provided with
actual utilisation figures to map against the outcome measures on both a monthly
and cumulative basis.
Part 4: TERMS AND CONDITIONS
4.1.1 Where a patient may lack capacity to consent to care or treatment, providers are
required to consider the Mental Capacity Act and the need to act in the best interests
of patients.
4.1.2 The CCG and the Contractor acknowledge the key principles of the NHS, and will
operate within all NHS standards, guidance, protocols and mandates.
4.1.3 This Contract forms part of the Contractor’s overall PMS, GMS or APMS contract or
PCTMS Statement and relevant clauses within the main contract/agreement will
apply.
4.1.4 The Contractor must ensure that it is able to provide any information that the CCG
may reasonably request of it to demonstrate robust systems are in place to maintain
any patient register. Any information supplied to the CCG must be accurate.
4.1.5 The CCG may challenge claims which are incomplete, duplicated or without
evidence, and this may result in delay of payment.
4.1.6 The Contractor must co-operate fully with any reasonable inspection or review that
the CCG or another relevant statutory authority wishes to undertake in respect of
these contracts.
4.1.7 Where fees are paid under this contract the CCG does not guarantee levels of
activity. Payment is based on accurate and reliable information and any calculations
must be carried out correctly.
49
4.1.8 The contractor will ensure that all services, including any administrative or supporting
processes, provided under this contract are performed under medical leadership.
4.1.9 The sub-contracting of clinical matters will be subject to:

GMS Contractors: Clause 370- 378 of the main GMS contract

PMS Contractors: Clause 385 – 389 of the PMS contract

Each party represents and warrants to the other that it has full power
and authority to enter into this Contract.
4.1.10 Except where indicated in the specifications and until further notice, the Contractor
will send all required reports and supporting evidence where applicable
electronically to [email protected] or to such other address / via
any other method as may be notified to the Contractor.
4.1.11 If the Contractor breaches any conditions of the contract the CCG may in
appropriate circumstances withhold payment or part payment which is otherwise
payable. Payment may be made following resolution of any outstanding queries.
4.2.1 Excluded Services
4.2.2 The CCG reserves the right to exclude services from the agreement. Specifically,
should the Department of Health include any of the proposed services within the
Quality and Outcomes Framework, these services will no longer be offered within this
specification.
4.3.1 Risk Management
4.3.2 It is the responsibility of the contractor to manage all risks associated with the
delivery of the services provided under this contract.
4.3.3 The Contractor will ensure it has a clear risk management policy for each service
included in this contract. Risk policies are to be held at the Contractors premises and
available should they be requested by the CCG for probity and contract review
purposes.
4.3.4 The risk management policy will include contingency plans to ensure periods of
absence, both planned and exceptional, are covered.
50
4.5.1 Termination of Agreement
4.5.2 This agreement will be reviewed by 31/1/2015.
This Contract may be terminated by either party by providing three months written
notice or by a mutually agreed date and confirmed in writing by both parties. The
CCG shall be entitled to terminate this local enhanced service agreement by notice in
writing to the provider if the provider commits any continuing or material breach of any
of the provisions of this agreement and, in the case of a breach capable of remedy,
fails to remedy the same within 28 days after receipt of a written notice giving full
particulars of the breach and requiring it to be remedied.
51
MINOR SURGERY
Specification for a Locally Commissioned Service
1st April 2014 – 31st March 2015
1. Introduction
The CCG needs to ensure that this service provides appropriate clinical care concentrating on high
priority and effective procedures, using good quality surgical techniques and good record keeping.
Procedures of unproven efficacy or solely for cosmesis or obviously benign unless symptomatic are
not commissioned.
Practices providing this Service will provide the full range of minor surgery specified in the
GMS/PMS contract as an additional service and no extra payments will be made for these services
(i.e. cautery, curettage and cryocautery of skin lesions, warts and verrucae).
This specification includes the requirements set out in the Primary Medical Services (Directed
Enhanced Services) (England) Directions 2008
2.
Scope of service to be provided
The following sites & indications will be paid for:
Suture removal (following procedures undertaken by a third party NHS body, e.g. A & E
departments)
Injections
 Shoulders in impingement syndrome or frozen shoulder
 Knees in acute injury or arthritis with effusion
 Wrists in carpal tunnel syndrome
 Tendon sheaths in trigger finger and DeQuervains
 Ligament and tendon insertions in tendonitis, epicondylitis and plantar fasciitis
Excisions & Incisions
 Lipomata or sebaceous cysts which are symptomatic, or on the scalp or other obvious places
 Lesions at moderate risk or suspicion of malignancy (highly suspicious moles should be referred
via the 2-week wait bureau) see guidance at paragraph 5
 Wedge incisions or full nail removal for ingrowing toenails
 Formal incision and drainage of an abscess including packing and dressing
Excision of the following requires prior approval from the CCG Priorities Panel:
 Symptomatic Skin tags
 Symptomatic Seborrhoeic warts
The following procedures will not be paid for as the CCG consider them to be either a low priority
treatment or to be part of ‘core’ services:
Injections
 Local anaesthetic injections
 Injections into muscle
 Acupuncture
 Sclerosant to varicose veins and haemorrhoids
Excisions
 Asymptomatic Skin tags
 Asymptomatic sebaceous cysts or lipoma
 Asymptomatic Seborrhoeic warts
 Ganglia
 Obviously benign naevi unless symptomatic
 Removal of foreign bodies
52

Insertion of ring pessaries
3.
Eligibility to provide the service
A practice may be accepted for the provision of this directed enhanced service if it has a partner,
employee or sub-contractor, who has the necessary skills and experience to carry out the
contracted procedures. These procedures should be in line with the principles of the generic GPs
with Special Interests (GPwSI) guidance, or the specific examples as they are developed. Clinicians
taking part in minor surgery should be competent in resuscitation and, as for other areas of clinical
practice, have a responsibility for ensuring that their skills are regularly updated. Doctors carrying
out minor surgery should demonstrate a continuing sustained level of activity, conduct regular
audits, be appraised on what they do and take part in necessary supportive educational activities.
Where a CCG believes a doctor carrying out minor surgery is not complying with the terms of the
contract it should invoke a remedial notice according to the procedure laid out in Regulation. There
is considerable guidance available on techniques and facilities for conducting minor surgery in
general practice.
4.
Criteria
Please note that the following criteria are nationally determined and are not subject to negotiation.
The Service requires GP practices to:
Satisfactory facilities
The Practice will have facilities that enable the clinician to properly
provide minor surgery in line with the NICE Clinical Guidelines : Infection
control, prevention of healthcare-associated infection in primary and
community care. http://guidance.nice.org.uk/CG2
Adequate and appropriate equipment should be available for the
Clinician to undertake the specified procedures, including, a suitable
room with sufficient space and appropriate equipment for resuscitation
Registered nurses can provide care and support to patients undergoing
minor surgery. Nurses assisting in minor surgery procedures should be
appropriately trained and competent, taking into consideration their
professional accountability and the Nursing & Midwifery Council
guidelines on the scope of professional practice.
Nursing support
Sterilisation and infection
control
The Practice must have, in writing, infection control policies that are
compliant with the NICE Clinical Guidelines : Infection control, prevention
of healthcare-associated infection in primary and community care.
Guidelines including inter alia the handling of used instruments, excised
specimens and the disposal of clinical waste.
The recommended standard for sterilisation and infection control is the
Guidelines.
The stan
The contractor must ensure it has appropriate arrangements in place for
Infection control and decontamination which should be either:

Use of sterile packs from local CSSD

Disposable sterile instruments

Approved local sterilisation procedures which comply with
national guidance
53
Consent
In each case the patient should be fully informed of the treatment options
and the treatment proposed. The patient should give written consent for
the procedure to be carried out and the completed consent form should
be filed in the patient's lifelong medical record.
Pathology
All tissue removed by minor surgery should be sent routinely for
histological examination unless there are exceptional or acceptable
reasons for not doing so.
Audit
Full records of all procedures should be maintained in such a way that
aggregated data, and details of individual patients are readily accessible.
Practices should regularly audit (minimum 1 p.a.) and peer-review minor
surgery work. Possible topics for audit include:
(a) clinical outcomes
(b) rates of infection
(c) unexpected or incomplete excision of basal cell tumours or
pigmented lesions which following histological examination are found to
be malignant.
Record keeping
Patient information
5.
Practices should collect data on a monthly basis for their own records,
this should be supplied to the CCG on a quarterly basis via the
Enhanced Services monitoring form. Data should be supplied with
total number of each procedure carried out along with free text
additional comments.
Practices must ensure that details of the patient's minor surgery
procedure as part of the Service is included in his or her lifelong record.
If the patient is not registered with the practice providing the DES, then
the practice must send this information to the patient's registered
practice for inclusion in the patient notes.
Removal of Skin Lesions
All GPs undertaking the removal of skin lesions within the Service for Minor Surgery must comply
with the National Institute for Clinical Excellence (NICE) Improving Outcomes Guidance for people
with Skin Tumours including Melanoma (IOG).
(http://www.nice.org.uk/Guidance/CSGSTIM/Guidance/pdf/English)
The guidance describes clearly the expected standards of care for patients with suspected and
diagnosed skin cancers. The IOG outlines a framework for patients with low risk Basal Cell
Carcinoma’s (BCC) to be diagnosed, treated and followed up under the management of clinicians
working in the community through the development of community skin cancer clinics delivered by
appropriately qualified clinicians.
Only General Practitioners whom have had their skin cancer diagnostic skills and skin surgery skills
assessed and been accredited by a representative of the local skin multidisciplinary team (LSMDT)
will be approved to remove low risk Basal Cell Carcinomas (BCC)
“Low risk BCC” is considered to be any BCC other than the following:
 Located on the Face, Scalp or Ears
Or
54
 2 cms or greater in size
Or
Have the following clinical indicators:
 Immunocompromised patient
 Genetically predisposed patient (e.g. Gorlins Syndrome)
 Previously treated lesion
 Flat lesion, hard thickened skin (appearance of morphoeic BCC)
All other suspected skin cancers, with the exception of high risk BCCs must be referred via the 2
week wait cancer referral route. High risk BCCs must be referred via the routine route in to the
secondary care dermatology provider.
It will be the responsibility of the primary care trust to maintain a register of accredited clinicians.
6.
Performance Monitoring
As a minimum, practices will need to ensure they keep activity information that records the
interventions carried out at an individual anonymised patient level. Clear identification of the
practitioner who carried out the intervention needs recording. The practice is required to supply the
CCG with such information it may reasonably request for the purposes of monitoring the contractor’s
performance of its obligations under the plan.
The contractor must supply the CCG with such information as it may reasonably request for the
purposes of monitoring the contractor’s performance of its obligations under the plan.
7.
Payment
Fees are as follows:
1. £44.19 per injection
2. £88.37 per excision or incision
3. Secondary care suture removal £525.92 per average practice per year on a retainer basis
(average practice list size is 5891. Calculation is therefore, practice list size/5891 x £525.92)
Activity data should be submitted on the Service Monitoring form on a monthly basis. Payments will
not be made without receipt of activity data.
Monthly anonymised patient activity data produced from the clinical system detailing the following
will be submitted to the CCG electronically to [email protected] every month in
Microsoft Excel format only.
o Patient ID Number (anonymised).
o Read code.
o Read code description.
o Details of procedure to include size, location and reason for removal.
o Date treatment done.
o
Failure to send this information to the CCG will result in a nil payment.
55
8.
Audit
MKCCG reserves the right to enter a practice and obtain access to relevant records to undertake an
audit of the enhanced service at any time. The objective of the audit would be to ensure that this
contract provides value for money to the CCG. The audit would check the adequacy of controls, the
integrity and reliability of information for billing in the area under review. This is to ensure that
payment is only made for valid work completed. The scope of the audit does not include checks on
the quality of activity. Practices would be given one weeks notice of attendance and will be required
to make the necessary records available. Each auditor would have appropriate authority from the
CCG, treat any records viewed with confidentiality, and provide clear ID.
9.
Termination/Alteration
The provider will give at least 3 months notice of the intention to terminate this agreement. In
exceptional circumstances the CCG may agree to reduce this period.
The CCG will give at least 3 months notice of any intention to change or terminate this agreement
allowing for the fact that currently the service runs to 31st March 2015.
Service specification – Minor Surgery
All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. The specification of this service is designed to cover the enhanced
aspects of clinical care of the patient, all of which are beyond the scope of essential services. No
part of the specification by commission, omission or implication defines or redefines essential or
additional services.
56
NEAR PATIENT TESTING
Specification for a Locally Commissioned Service
1st April 2014 – 31st March 2015
Introduction
The treatment of several diseases within the fields of medicine, particularly in rheumatology, is
increasingly reliant on drugs that, while clinically effective, need regular blood monitoring. This is
due to the potentially serious side-effects that these drugs can occasionally cause. It has been
shown that the incidence of side-effects can be reduced significantly if this monitoring is carried out
in a well-organised way, close to the patient’s home’
Aims
The near patient testing service is designed to be one in which:
1. therapy should normally be initiated in secondary care for recognized indications for specified
lengths of time
2. maintenance of patients first established in the secondary care setting should be properly
controlled
3. the service to the patient is convenient
4. the need for continuation of therapy is reviewed regularly
5. the therapy is discontinued when appropriate
6. the use of resources by the National Health Service is efficient
7. the service takes account of local and national guidance on safety issues
Service Outline
The service is to provide:
A shared care drug
monitoring service
In respect of the following drugs:
(a) Penicillamine
(b) Auraofin
(c) Sulphasalazine
(d) Methotrexate
(e) Sodium Aurothiomalate (Gold).
(f)
Those drugs included in the MK Medicines and
Therapeutics Committee ’s Amber List (Shared Care Drugs)
detailed in the attached Annex, where a Shared Care Protocol
is in place
Register
Practices should be able to produce and maintain an up-to-date
register of all shared drug monitoring service patients, indicating
patient name, date of birth and the indication and duration of
treatment and last hospital appointment
Call and Recall
To ensure systematic call and recall of patients on this register is
taking place either in a hospital or general practice setting
Education and
newly diagnosed
patients
To ensure that all newly diagnosed/treated patients (and/or their
carers when appropriate) receive appropriate education and advice
on management of and prevention of secondary complications of
their condition. This should include written information where
57
appropriate
Continuing
Information for
Patients
To ensure that all patients (and/or their carers and support staff
when appropriate) are informed of how to access appropriate
relevant information. The NPSA has issued specific guidance on
methotrexate which must be followed
Individual
Management Plans
To ensure that the patient has an individual management plan,
which gives the reason for treatment, the planned duration, the
monitoring timetable and, if appropriate, the therapeutic range to
be obtained
Professional Links
To work together with other professionals when appropriate. Any
health professionals involved in the care of patients in the
programme should be appropriately trained
Referral Policies
Where appropriate to refer patients promptly to other necessary
services and to the relevant support agencies using locally agreed
guidelines where these exist
Record Keeping
To maintain adequate records of the service provided,
incorporating all known information relating to any significant
events e.g. hospital admissions, death of which the practice has
been notified
Training
Each practice must ensure that all staff involved in providing any
aspect of care under this scheme have the necessary training and
skills to do so
Performance Monitoring
As a minimum, practices will need to ensure they keep activity information that records the
interventions carried out at an individual anonymised patient level. Clear identification of the
practitioner who carried out the intervention needs recording.
The contractor must supply the CCG with such information as it may reasonably request for the
purposes of monitoring the contractor’s performance of its obligations under the plan.
Untoward Events
It is a condition of participation in this service that practitioners will be give notification to the CCG
clinical governance lead of all emergency admissions or deaths of any patient covered under this
service, where such admission or death is or may be due to usage of the drug(s) in question or
attributable to the relevant underlying medical condition. This must be reported within 72 hours of
the information becoming known to the practice. This is in addition to the practitioner’s statutory
obligations.
Accreditation
Those doctors who had previously provided services similar to this enhanced service and who
satisfy at appraisal and revalidation that they have such continuing medical experience, training and
competence as is necessary to enable them to contract for the enhanced service shall be deemed
professionally qualified to do so.
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Audit/Review
All practices involved in the scheme should perform an annual review which could include:
1. brief details as to arrangements for each of the aspects highlighted in the service
2. details as to any computer-assisted decision-making equipment used and
arrangements
for internal and external quality assurance
3. details as to any near-patient testing equipment used and arrangements for internal and
external quality assurance
4. details of training and education relevant to the drug monitoring service
5. details of the standards used for the control of the relevant condition
6. assurance that any staff member responsible for prescribing must have developed the
necessary skills to prescribe safely.
Payment
The funding detailed below assumes the practice meets all of the criteria in this service
specification. Prices are per patient per year
Level 3 - Practice-funded phlebotomist or pharmacist etc.,
Practice sample, laboratory test, practice dosing
£104.94
In addition to the above fees, where sampling requires a domiciliary visit to a housebound patient on
behalf of the practice, and not by a member of staff employed by an NHS body to provide
community health services, an additional fee would be paid for each separate address visited on
that day
£4.34
Payment will be made monthly following the submission of the following data.
Monthly anonymised patient activity data produced from the clinical system detailing:



Patient ID number (anonymised)
Read code
Date treatment done
Failure to send this information to the CCG will result in a nil payment.
Audit
MKPCT reserves the right to enter a practice and obtain access to relevant records to undertake an
audit of the enhanced service at any time. The objective of the audit would be to ensure that this
contract provides value for money to the CCG The audit would check the adequacy of controls, the
integrity and reliability of information for billing in the area under review. This is to ensure that
payment is only made for valid work completed. The scope of the audit does not include checks on
the quality of activity. Practices would be given one weeks notice of attendance and will be required
to make the necessary records available. Each auditor would have appropriate authority from the
CCG, treat any records viewed with confidentiality, and provide clear ID.
Termination/alteration
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The provider will give at least 3 months notice of the intention to terminate this agreement. In
exceptional circumstances the CCG may agree to reduce this period.
The CCG will give at least 3 months notice of any intention to change or terminate this agreement
allowing for the fact that currently the service runs to 31st March 2015.
Service specification– Near Patient Testing
All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. The specification of this service is designed to cover the enhanced
aspects of clinical care of the patient, all of which are beyond the scope of essential services. No
part of the specification by commission, omission or implication defines or redefines essential or
additional services.
Annex 1
AMBER LIST:



Azathioprine
Cyclosporin
Leflunomide
Refer to http://nww.mkhospital.nhs.uk/pathfinder/navigate.asp?DocType=1&SpeType=56
for shared care protocols for the following drugs:
Cyclosporin Therapy in Rheumatology Arthritis
Azathioprine Therapy in Rheumatoid Arthritis
D-Myocrisin Therapy in Rheumatoid Arthritis
D-penicillamin Therapy in Rheumatoid Arthritis
Leflunomide Therapy in Rheumatoid Arthritis
Methotrexate in Rheumatology Arthritis
Sulfasalazine Therapy in Rheumatoid Arthritis
Further information on these and other drugs should be obtained from the British National
Formulary and Summary of Product Characteristics (SPC) for each drug. Special care is
necessary in pregnancy. Please refer to the latest BNF for details of potentially hazardous
drug interactions. Clinical responsibility lies with the prescriber. The Pathology Users
Handbook is available from Milton Keynes General Hospital or their intranet site. The
document provides guidance on choice of collection bottle, availability of services etc
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NEONATAL CHECKS
Contract for a Locally Commissioned Service
1st April 2014 – 31st March 2015
Introduction
Every neonate should have a thorough physical examination within the first week after birth. This
constitutes the first part of the Child Health Promotion Programme and is not an examination to
ascertain fitness for discharge from the hospital. It is also an opportunity for health promotion.
The purpose of the examination is to:
 Check for physical health and the absence of abnormalities
 Ascertain parental concerns and reassure parents where possible
 Initiate the action required when problems are found
Service Outline
This locally enhanced service will fund:

Neonatal Checks (as outlined in Appendix A) performed by General Practitioners on babies
born at home, staying in hospital for less than 6 hours or going home at short notice in
accordance with locally agreed guidelines.
These should ideally be performed between 24-72 hours following birth but not before 6
hours of age and no later than 7 days of age.

Reporting Procedure
In addition to a clear entry in the child’s medical record (electronic or paper) a record of the
neonatal examination must normally be made on the 3-part Birth Details form within the
Personal Child Health Record held by the parent. The bottom (yellow) copy should then be
forwarded to the Child Health Department. Submission of this form will trigger payment for
the neonatal check so it is be important to ensure that these are stamped with the
practice stamp to enable the CCG to identify the service provider. Incomplete forms
will be returned to the practice for completion prior to any payment being made.
Where the Personal Child Health Record held by the parent is not available the practice can
use a loose-leaf version of the Birth Details form but must ensure that a copy is transferred
to the Personal Child Health Record held by the parent.

This claim may be subject to post payment verification and a contemporaneous note in the
medical record will normally provide evidence that the examination has been done
Accreditation
Practices are responsible for ensuring that the doctor performing the examination is competent to do
so.
Monitoring
The contractor must supply the CCG with such information as it may reasonably request for the
purposes of monitoring the contractor’s performance of its obligations under the plan.
Costs
In 2014-15 each practice contracted to provide this service will receive £55.23 for each neonatal
check carried out within the timescales specified above.
Payment
Payment will be made monthly based on the number of completed reports, received by the Child
Health Department, of checks undertaken by the GP practice in the preceding 3 months.
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Audit
MKCCG reserves the right to enter a practice and obtain access to relevant records to undertake an
audit of the enhanced service at any time. The objective of the audit would be to ensure that this
contract provides value for money to the CCG. The audit would check the adequacy of controls, the
integrity and reliability of information for billing in the area under review. This is to ensure that
payment is only made for valid work completed. The scope of the audit does not include checks on
the quality of activity. Practices would be given one weeks notice of attendance and will be required
to make the necessary records available. Each auditor would have appropriate authority from the
CCG, treat any records viewed with confidentiality, and provide clear ID.
Termination/Alteration
The provider will give at least 3 months notice of the intention to terminate this agreement. In
exceptional circumstances the CCG may agree to reduce this period.
The CCG will give at least 3 months notice of any intention to change or terminate this agreement
allowing for the fact that currently the service runs to 31st March 2015.
Service Specification – Neonatal checks
All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. The specification of this service is designed to cover the enhanced
aspects of clinical care of the patient, all of which are beyond the scope of essential services. No
part of the specification by commission, omission or implication defines or redefines essential
services.
Appendix A NICE Routine postnatal care of women and their babies Issue date: July 2006
Physical examination and screening
The aims of any physical examination should be fully explained and the results shared with the
parents and recorded in the postnatal care plan and the personal child health record.
A complete examination of the baby should take place within 72 hours of birth. This examination
should incorporate a review of parental concerns and the baby’s medical history should also be
reviewed including: family, maternal, antenatal and perinatal history; fetal, neonatal and infant
history including any previously plotted birth-weight and head circumference; whether the baby has
passed meconium and urine (and urine stream in a boy). Appropriate recommendations made by
the NHS National Screening Committee should also be carried out
www.nsc.nhs.uk/ch_screen/child_ind.htm
A physical examination should also be carried out. This should include checking the baby’s:











appearance including colour, breathing, behaviour, activity and posture
head (including fontanelles), face, nose, mouth including palate, ears, neck and general
symmetry of head and facial features. Measure and plot head circumference
eyes; check opacities and red reflex
neck and clavicles, limbs, hands, feet and digits; assess proportions and symmetry
heart; check position, heart rate, rhythm and sounds, murmurs and femoral pulse volume
lungs; check effort, rate and lung sounds
abdomen; check shape and palpate to identify any organomegaly; also check condition of
umbilical cord
genitalia and anus; check for completeness and patency and undescended testes in males
spine; inspect and palpate bony structures and check integrity of the skin
skin; note colour and texture as well as any birthmarks or rashes
central nervous system; observe tone, behaviour, movements and posture. Elicit newborn
reflexes only if concerned
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


hips; check symmetry of the limbs and skin folds (perform Barlow and Ortolani’s
manoeuvres)
cry; note sound
weight; measure and plot.
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