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  2. 2. MODULE B – PERFORMANCE REQUIREMENTS – SPECIFICATION, QUALITY AND PRODUCTIVITY SECTION 1 – SPECIFICATION Care Pathway/Service Community based dermatology services Commissioner Lead Adrian Metcalf, Planned Care Policy Lead, NHS County Durham Provider Lead Period 3 years from contract award date with annual service specific performance review Applicability of Module E (Acute Services Requirements) 1. Purpose 1.1 Aims Using the Any Willing PCT Provider route, NHS County Durham wishes to commission community or primary care based dermatology services which will provide the capacity for a wide range of referrals to be dealt with in line with recognised best clinical practice. In developing a service model with clinical pathways, the provider(s) of the community based dermatology service (hereafter referred to as the “service” or “services”) must be able to demonstrate the following: 1.1.1 Improved quality and effectiveness of services for people who have a dermatological condition. 1.1.2 Innovative approach to service provision, which may include Consultants, GPs with a Special Interest, Specialist Nurses, pathology and pharmacy. 1.1.3 Provision of timely and efficient triage of referrals for patients ensuring personalised care in the right place and as close to home as possible, by the most appropriate clinician. 1.1.4 Provision of equitable access for all patients of the service covering: a. The provision of a comprehensive range of treatments. b. Consistent waiting times. c. Consistent standards of service. d. The ability to flex resources where capacity is needed. 1.1.5 Joined up service provision across the patient pathway: a. Good relationships and robust referral pathways across primary and secondary care. b. Robust clinical governance arrangements. c. Improved waiting times between referral and access to specialised clinical services. d. Pathways that ensure that all patients are treated within 18 weeks of referral by the GP. 1.1.6 Arrangements for consultant supervision of service staff (and ongoing development of service staff in all locations) where required. 1.1.7 Provision of education and training for all referrers. 1.1.8 Provision of education and advice for all newly diagnosed or treated patients on the management of their condition. 1.1.9 Provision of timely and accurate clinical information to referrers and performance information to the commissioner. 1.1.10 Provision of a high quality service that represents value for money. Page 2 of 25
  3. 3. 1.1.11 Accreditation of the service and all practitioners with a special interest working within the service. 1.1.12 Compliance with the Core Standard 7a of the Standards for Better Health Framework and where skin surgery services are to be provided as part of the community service the service must be compliant with the guidance document “Improving outcomes for people with skin tumours including melanoma” (NICE, 2006). 1.2 Evidence Base The current range of community-based dermatology services in County Durham and Darlington have historically developed through locality-based commissioning (within the former PCTs). This has created a good range of locality based primary care led services providing high quality specialist medical and nursing expertise closer to the patients’ home, thus preventing the need for care in the hospital setting for some benign and chronic diseases. In addition to local evidence of effectiveness, community based dermatology services are recommended by the following publications: • Action on Dermatology. Good Practice Guide. NHS Modernisation Agency, Department of Health. Jan 2003 • Department of Health (2007) Guidance and Competencies for the Provision of Services Using GPs with Special Interests (GPwSIs): Dermatology and Skin Surgery. London: Department of Health. Service gaps remain in Durham and Chester-le-Street and Sedgefield and significant activity levels appropriate for a community based service continue to go to the hospital based dermatology services. Through this specification, the PCT will build on existing service models by commissioning modernised and robust services based upon the strategic vision and objectives of the PCTs, which takes advantage of Practice Based Commissioning and Payment by Results regimes. The key principles of the service will be consistent with Government policy and guidance: • Shaping personalised services (World Class Commissioning, DH 2007). • Care closer to home (Creating a patient led NHS, DH 2005). • Personalised services, choice and control, health and wellbeing (The Operating Framework for the NHS in England 2008/09, DH 2007). • Secondary to primary care shift (Our Health, Our Care, Our Say: a new direction for community services, DH 2006). A number of key clinical guidelines and technology appraisals are also applicable to this specification, including, but not limited to, the following: • NICE Guidance • IOG – Skin tumours including melanoma • CG57 – Atopic eczema • TA82 - Atopic dermatitis • TA177 – Eczema • TA103/134/146/180 – Psoriasis • TA199 – Psoriatic arthritis • British Association of Dermatologists Guidance 1.3 General Overview The services will provide non-surgical dermatology for both adults and children. All patients will be registered with a General Practitioner of a County Durham or Darlington practice. The existing service gaps cover the Durham and Chester-le-Street practices (population 155,000) and Sedgefield practices (population 90,000). 1.4 Objectives 1. To reduce unnecessary treatment in a secondary care setting. 2. To maximise the appropriate use of primary and community care based services and facilities. Page 3 of 25
  4. 4. 3. To ensure the sustainability of the 18 weeks target. 4. To provide care closer to home. 1.5 Expected Outcomes The service will provide for the diagnosis, treatment and continuing care of a range of skin conditions helping patients to manage and improve their conditions and lead normal, healthy and active lives. 2. Scope 2.1 Service Description The service will provide non-surgical dermatology for both adults and children. Surgery for low risk basal cell carcinomas may be undertaken only by consultants or GPs who have been accredited as having a special interest in skin surgery following community dermatology or consultant triage. Suspected cancer – all referrals will be directed immediately to a consultant clinic in a hospital setting. Should such a referral be received by the service it should be reported to the PCT as an incident. 2.2 Accessibility/acceptability The service provider will be responsible for ensuring that equity of access is maintained across all treatment pathways. In determining the most appropriate clinical setting for the treatment of the patient’s condition, the commissioner has produced a tiered model as guidance for the referrer attached as Appendix 1. The service is expected to cover the conditions listed in the Community Dermatology Service (blue) section. It is recognised that the clinical competency of service providers will vary and the provider is expected to notify the commissioner of any required variation to the list of conditions described in the model in Appendix 1. 2.3 Whole System Relationships In line with Aims 1.1.2, 1.1.5 and 1.1.6, the service will be required to contribute to a joined up pathway across primary and secondary care. The service provider will be responsible for ensuring that it maintains a staffing complement which allows it to meet the objectives set out in this Specification. In particular, all staff will be required to work flexibly to ensure continuity of care and equity of access across all sites and treatment pathways. 2.4 Interdependencies As described above. 2.5 Relevant Clinical Networks and Screening Programmes North East Cancer Network Primary Care Dermatology Society British Association of Dermatologists 2.6 Sub-contractors For local agreement on award of contract. Pathology The service provider should establish or have established links with pathology departments and have access to sufficient capacity in order to meet demand as well as robust tracking and audit processes. There will also be Page 4 of 25
  5. 5. arrangements in place for clinical discussion between the pathologist and the requesting clinician and for the pathologist to participate in skin cancer multi-disciplinary teams. Other Resources The following list describes the resource requirements that would be expected of a community-based dermatology service as a minimum. The list is not exhaustive and should be used as a guide. • Complete access to diagnosis and treatment in convenient geographical locations. • Access to a registered and trained dermatology specialist nurse in all clinic locations who will also be responsible to ensure decontamination and infection control procedures are managed as per County Durham and Darlington Primary Care Trusts Policies. • Access to consultation rooms and appropriate facilities for diagnosis and treatment procedures. • Administrative support to ensure that clinics are organised and reported. This will include support to book clinics; manage and report waiting lists, manage and store patient records; provide the necessary statistical returns. • Records are maintained by the service and the referring General Practitioner and the patient is provided with a copy of treatment details on completion of the episode of care or as part of on-going management. • The service provider will have a commitment to moving towards an integrated health record for all patients into the service. • Information Technology and arrangements for IT support. 3. Service Delivery 3.1 Service Model, Staffing and Skill Mix A key aim of this service is to develop an innovative approach to service provision, which may include GPs with a Special Interest, Specialist Nurses, Consultants, pathology and pharmacy. As a minimum, in fulfilling the requirements of this specification, the service will be expected to provide: • A range of community dermatology level care covering the conditions listed under the Community Dermatology Service (blue) section as shown in Appendix 1. In addition, the service may offer a range of specialist nurse led care including: o Cryotherapy o Camouflage o Dermojet treatments o Dithranol treatments o a full range of dressings to support the treatment and management of appropriate skin conditions Surgery for low risk basal cell carcinomas may be undertaken only by consultants or GPs who have been accredited as having a special interest in skin surgery following community dermatology or consultant triage. All other surgery for skin cancers will be undertaken in secondary care. Should such a referral be received by the service it should be reported to the PCT as an incident. It is possible that the skills and competencies of specific staff groups may develop beyond the role expectiations set out in this Specification. For example, specialist nurses may take on functions allocated to medical staff in this Specification. Where such developments take place, this will only happen when: • the person concerned is duly accredited to do so by the commissioner. • the arrangement has the agreement of the lead Medical Practitioner for the locality. Page 5 of 25
  6. 6. The following sections provide the commissioner’s expectations of the possible staff groups involved in the service. 3.1.1 Consultant When consultants are directly involved in the provision of the service, at a minimum they must: • Provide supervision of the GPs with Special Interests (GPwSIs) in Dermatology • Provide teaching, training, development and mentoring of team members • Appraisal • Participating on service improvement plans • Continued Professional Development (CPD) for self and others • Clinical governance leadership Consultant staff will work with team members and others to ensure the continued improvement and excellence of the service. Consultants may wish to consider offering an Integrated Training Programme through teaching clinics for both the development of new GPwSIs and education for the referrers, e.g. on a rotational basis. 3.1.2 Non Consultant Medical Staff Non Consultant medical staff can include a range of staff, including GPwSIs, GP Registrars, Staff Grades, Associate Specialists, Specialist Registrars. Non Consultant medical staff can operate in either a Primary or Secondary Care setting depending on qualifications and expertise. Specific roles will vary according to the qualifications of the individual, but in general, Non Consultant medical staff will cover: Clinical Responsibilities: • See “community dermatology service” level patients (see Appendix 1), undertaking appropriate investigations, diagnosing their conditions, and recommending treatments in line with agreed policies and guidelines. • When appropriate refer the patient back to their GP with advice for ongoing management. • When appropriate refer the patient for consultant opinion in line with PCT policies and guidelines, for example for “secondary care dermatology service” conditions. • In conjunction with appropriately trained nursing staff run chronic disease clinics for patients with psoriasis, acne and eczema. Service delivery and strategy: • Contribute to the streamlining of patient care (using the "care pathway" approach) including: o Development and implementation of agreed referral guidelines. o Development of the primary care component of patient care pathways. o Participation in the PCT planning and practice based commissioning forums. o Improving communication and raising awareness with general practices in relation to dermatology. • Contribute to local dermatology service development and, where appropriate, to represent the service in dermatology networks. • Assist in ensuring that agreed standards are adopted across the whole of the PCT, including appropriate nurse led services, and are comprehensive and flexible and meet the needs of patients. Standards of dermatology practice within primary care: • Contribute to the establishment of appropriate IT support algorithms to support the delivery of evidence based dermatological treatments. • Implement a quality assurance programme in conjunction with the Clinical Governance leads. • Liaise with the PCT prescribing team and advise on the implementation of national and local guidance in relation to the dermatological therapeutics. Page 6 of 25
  7. 7. • Provide educational input to general practice and PCT learning plans for dermatology, and more widely if appropriate. • Identify the skills deficit in order to manage minor disorders, and develop and deliver training programmes to GPs. Professional development, education and governance: • Have current GMC registration, without restrictions to practice, have a current license to practice and, if a GP, be a member of a PCO Medical Performers List. GPwSIs must be working at least one session per week as a GP to retain accreditation status. • Remain up-to-date professionally by undertaking continuous professional development. In the case of GPwSIs this will involve a minimum of 15 hours Continuous Professional Development per annum in their specialist area and annual appraisal which covers both specialist and generalist areas. • Undertake or participate in regular clinical audit projects relevant to the clinical care provided. Attendance at dermatology audit sessions is required. Minimum attendance at MDT meeting of 4 times per year for those removing BCCs. • To participate in agreed research programmes. • To contribute to the training and educational programme of other health professionals in the PCT. • Up-to-date enhanced CRB disclosure (or ISA equivalent). 3.1.3 Nursing Team (supported by administrative staff) Generally, the Nursing Team is required to: • Coordinate and manage referrals, ensuring equal and timely access into the range of diagnostic and treatment services. • Develop nurse led clinic sessions and take responsibility for the delivery and quality of services to all patients requiring treatment. • Liaise with staff across primary and secondary care services and also to access regional diagnostic and specialist services as required. • Act as an expert resource/reference point for primary care. • Give support to patients and relatives. Specifically, the Nursing Team is to provide or assist: As part of a community dermatology service: • Patient/Carer education on emollient therapies and individual management plans. • Management of follow-up appointments for patients with diagnosed conditions eg eczema and psoriasis, to evaluate the impact of their individual management plan prescribed by the Consultant or General Practitioner with Special Interest. • Evaluation of treatments and provide on-going advice and support for patient with chronic long term conditions. • Rapid access clinics for patient’s known to the service but experiencing a ‘flare up’. • Wet wrapping for eczema patients. • Pre-operative investigation and assessment where required. • Nail clippings. • Skin scrapings. All members of the nursing team must have current NMC registration and have an up-to-date enhanced CRB disclosure (or ISA equivalent). 3.1.4 Workforce development The provider will ensure that staff are suitably trained, qualified and competent to deliver the service. All clinical professional staff will be registered with their professional body and abide by their professional rules and regulations. It will be the provider’s responsibility to ensure that registration is current. Providers of services must be able to demonstrate that their workforce policies, processes and practices comply with all relevant applicable UK employment legislation and best practice (these provisions would also apply to locums and sub contractors). Page 7 of 25
  8. 8. Providers must comply with the provisions of: • The NHS Employment Check Standards (see separate section) • Standards for Better Health (SBH); and • The Code of Practice for the International Recruitment of Healthcare Professionals (December 2004) (The Code of Practice for International Recruitment is only applicable where any international recruitment is planned). • Cabinet Office Code of Practice on Workforce Matters in the Public Sector and the annex to it, A Fair Deal for Staff Pensions and the NHS Staff Passport 3.1.5 Employment policy and practice The service provider must: • Keep up-to-date with current applicable UK employment and equalities legislation and associate codes of practice; • Keep an appropriate audit trail of CRB checks, which will be made available to the commissioner on request. (with renewals of checks being carried out at three yearly intervals). Provision for assurance related to CRB checks is described in Appendix 2; • Appraise and assess the practical competency of all staff to carry out the duties of the roles and manage their performance. The provider must ensure that all staff (of all grades and professions) who are directly involved in supporting the services, have the necessary training, qualifications, experience, competence and skills to undertake these roles (and possess the relevant indemnity insurance); • Ensure that robust induction and mandatory training programmes and clinical supervision as necessary are in place; • Identify and address staff conduct and performance issues arising from patient complaints; • Ensure there are contingency plans in place to cover for planned and unplanned absence; • Ensure that there are robust arrangements in place to ensure that staff maintain their professional registration and that lapsed registrations are prevented; and • Ensure that staff will be adequately trained and competent to deal with medical emergencies safely and appropriately. • Ensure that the workforce management information systems must be capable of monitoring compliance with the Working Time Regulations 3.2 Clinical effectiveness and NICE guidance This specification requires: • Adherence to the principles of clinical governance and best practice in line with NICE Guidance, and other relevant national and local guidelines including NSFs, Standards for Better Health and the Primary Care Trust Clinical Governance Framework. • Implementation of these principles will be monitored through the normal contract review processes. • Clinical Governance arrangements must be proportionate to the service provided and comply with any local expectations or requirements of the commissioner. Providers should consider the Department of Health (2007) document Guidance and competencies for the provision of services using GPs with Special Interests. 3.3 Accreditation The function of accreditation is to ensure ‘fitness for purpose’ through accreditation of both the services themselves, and individual CSIs (Clinicians with a special interest) / GPwSIs working within them. In addition, the accredited individuals or services should consider the ways in which they can improve quality and further raise standards. The provider applying for accreditation must understand the service specification including: • Defined patient inclusion and exclusion criteria. • Referral arrangements to and from all services. • How the service communicates and integrates with clinical networks. Page 8 of 25
  9. 9. • Physical, human, audit and financial resources required to deliver the service. • Robust integrated governance arrangements. • Support required from other health and social care professionals and services. • Evidence of the ways in which local people have been involved in developing and planning the service. • A clear definition of the role the individual clinician will play within the service. • Arrangements for the clinicians ongoing professional development. • Appropriate indemnity cover required. • Compliance with Standards for Better Health. The process of accrediting an individual should assure patients and commissioners that they operate within a coherent and quality-assured clinical pathway and that they maintain the highest possible standards of clinical governance. The Care Quality Commission will take this into account in its inspections of primary care trusts (PCTs) for the core standards assessment. (The standards particularly relevant to the accreditation are C5b, C5d, C10a, C10b, C11a, C11b and C11c.) 3.4 Standards for Better Health Providers should comply with best practice guidance as set out in Standards for Better Health. Providers are also expected to comply with all relevant professional guidance and legislation in respect of provision of safe and effective health care provision. Any system of clinical governance operated by the Provider shall be fully compliant with Core Standard 7a of the Standards for Better Health Framework and complement the PCT’s Clinical Governance Framework. 3.5 Infection control The Health Act for the Prevention and Control of HCAI 2008 summarises existing guidance, and identifies the key management actions to be taken. The provider must be able to demonstrate assurance of compliance with the Health Act October 2006. 3.6 Decontamination of equipment and single use devices For new service introduction, the infection control audit tool pertinent to the area allocated for use for a specific service must be satisfactorily completed. 3.7 Premises Should the provider rent space in a commissioner operated facility they will be required to pay rent for the facility use and will be required to enter into a licence agreement for the sessional use of space in these facilities. Heads of terms must be agreed prior to commencement of the service occupancy/delivery. The provider will be required to meet reasonable service costs for the facility on a pro rata basis. Any charges which are directly attributable to the service will also be specified in the licence agreement and billed accordingly. 3.8 Medicines Management All prescribers must adhere to both legal and good practice guidance on prescribing and medicines management in line with the Medicines Act 1968, associated legislation and regulations. All prescribers must engage in quality and cost effective prescribing in the context of overall use of NHS resources. An impact assessment must be performed in relation to prescribing costs and procurement of medicines. Medicines procured for the purpose of supply to service users must be purchased from a provider with the necessary Medicines and Health Care Products Regulatory Agency (MHRA) authorisation, labelled and Page 9 of 25
  10. 10. supplied in accordance with the European Labelling and Leaflet Direction 92/27,2001/83/EC Directive and the Medicines Act, and auditable. Standard prescription charge rules and exemptions apply to all clients receiving a supply of medicines from NHS funded services. Prescribers will comply with all the statutory regulatory requirements for the safe and secure management of controlled drugs. Prescribers will complete an annual declaration on whether or not the organisation keeps stocks of controlled drugs. Those that do hold stock of controlled drugs will be required to complete a self assessment of their management of controlled drugs. Prescribers will implement National Patient Safety Alerts and Drug Alerts within the time frame specified in the alerts. Patient Group Directions must be authorised for use by the PCT and comply with the PCT Patient Group Direction Policy and the Health Service Circular (HSC) 2000/026. Prescribers will comply with the Health Care Commission Standards for Better Health Core Standard C4(d); medicines are handled safely and securely; and C4(e); the prevention, segregation, handling, transport and disposal of medicines is properly managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment. 3.9 Risk Management The community dermatology service will operate within the Infection Control Policy directives related to: • Decontamination Policy • Medical Devices Policy • Hand Washing Policy • Disposal of Clinical Waste including Sharps • Protective Clothing Policy • Environmental Cleaning Policy Each premises must comply with NHS Estates standards and have an operational guideline for the service provided. This includes an environmental risk assessment and a COSHH assessment. Practitioners will follow agreed treatment protocols for cryotherapy. All primary care staff (nursing and medical) employed to provide the service will achieve accreditation to the agreed level to demonstrate competence. All staff employed to provide the service must be bi-annually trained in resuscitation techniques and the management of anaphylactic shock. 3.10 Informatics Requirements Providers must submit monthly the data listed in the minimum data set in Appendix 3 parts A and B. The same data requirements will be formalised through the appropriate schedule of the contract. 3.11 National Patient Safety Notices Providers will have a mechanism for receiving, disseminating and implementing Central Alert System and NPSA notices and must provide the commissioner with assurance of implementation when requested. 3.12 Significant event and adverse incident reporting A full report on patient complications should be made back to the referring clinician and all near misses, Page 10 of 25
  11. 11. adverse incidents investigated and reported in accordance with published Commissioner policies. 3.13 Confidentiality There should be a documented Confidentiality and Management of Information policy, which sets out how the organisation ensures that information held about people referred and staff is managed confidentially. All relevant staff must be aware of the policy and documented evidence of implementation. 3.14 Consent All invasive procedures carried out will require consent to be obtained and documented. In each case the patient will be fully informed of the treatment options and the benefits and risks of the treatment proposed. Systems must be in place to ensure that the consent is permanently recorded in the patient’s records. Everyone aged 16 years or more is presumed to be competent to give consent and in the case of those under the age of 16 some one with parental responsibility may do so on their behalf. If a young person under the age of 16 years has “sufficient understanding and intelligence to enable him or her to understand fully what is proposed” then he or she will be competent to give consent for him or herself. Where it is assessed that an adult lacks capacity to consent then the procedures within the Mental Capacity Act will be adopted and an Independent Mental Capacity Advisor (IMCA) will be contacted if required. If the patient is over 18 years and not legally competent to give consent all reasonable steps should be taken to ensure the involvement of those who can support the patient in their understanding and provide guidance as to the appropriate method of achieving consent for that individual. If a photograph is to be taken as part of the patients care record a separate consent form must be used. Different levels of consent must be obtained if the image is to be used for educational purposes or publication and a record of the consent must remain with the patient’s record. 3.15 Pathways See Appendix 1 for high level tiered service model. Detailed pathways are to be developed and proposed by the service provider. This tiered model will be used as guidance for referrers, therefore any narrowing or widening of the scope must be with the prior agreement of the commissioner. 4. Referral, Access and Acceptance Criteria 4.1 Geographic coverage/boundaries All patients will be registered with a General Practitioner of a County Durham PCT or Darlington PCT practice. The existing service gaps cover the Durham and Chester-le-Street practices (population 155,000) and Sedgefield practices (population 90,000). 4.2 Location(s) of service delivery The service will be provided from appropriately equipped premises within the boundary of County Durham and Darlington. Suitable premises may include Primary Care Centres, community hospitals, general hospitals and general surgeries with appropriate facilities. The exact service locations will be influenced by several factors and cannot be defined as part of the service specification: • Locality in which the service is to be commissioned. • Availability of suitable premises in the locality. • Premises belonging to the willing provider. • Negotiation between service provider and PCT or landlord. Page 11 of 25
  12. 12. • Affordability and agreement of rental rates and other accommodation expenses. Subject to the availability of suitable premises, the service should be located with access by regular public transport. 4.3 Days/Hours of operation The service opening hours will be by agreement with the PCT however the service will be required to offer appointments between the core clinical hours of 9am and 5pm on the days on which the service operates. Evening and weekend working will be by mutual arrangement with the PCT. The service (with cover arrangements agreed with the PCT, if necessary) will be available throughout the year at a frequency that ensures that sufficient capacity exists to meet demand and that waiting time standards are achieved. The provider(s) must ensure flexible capacity to cope with seasonal and unexpected changes in demand. 4.4 Referral criteria and sources In determining the most appropriate clinical setting for the treatment of the patient’s condition, the commissioner has produced a tiered model as guidance for the referrer attached as Appendix 1. It is recognised that the clinical competency of service providers will vary and the provider is expected to notify the commissioner of any required variation to the list of conditions described in the model in Appendix 1. 4.5 Referral route All referrals should be accepted through Choose & Book (C&B) where the referrer has access to the national British Telecom NHS N3 secure network. 4.6 Exclusion Criteria The Tiered model described in Appendix 1 lists the exclusions applicable to all levels of service (red section). The service must not perform any of the procedures on the Exclusions list. The commissioner will not be responsible for paying for any activity on the Exclusions list carried out by any service provider. The treatment of any condition using a laser MUST be given authorisation by the commissioner prior to referral (red section). 4.7 Response time and prioritisation In accordance with national targets, Referral to Treatment Times (RTT) must be within 18 weeks. All suspected cancers should be referred immediately to secondary care and will also be within timescales in accordance with national targets. 5. Discharge Criteria and Planning It is the responsibility of the referrer to ensure that all the necessary work-up is completed prior to referral and all such work-up including results is detailed in the referral form. Discharge Arrangements for discharge will be documented and agreed with the PCT and will include: • patient information on management of the condition • a discharge information template to be sent to the referrer Page 12 of 25
  13. 13. • an agreed policy for discharged patients with recurrence of the condition and flare-ups • an agreed policy for the treatment of patients who do not attend their appointment (did not attend – DNAs - and Could not attend - CNAs. Discharge summary information will be sent to the patient’s GP within 24 hours of discharge from the service. All practices in County Durham and Darlington have an email address to receive discharge information. Page 13 of 25
  14. 14. 6. Prevention, Self-Care and Patient and Carer Information All patients will receive non-promotional written information to provide support following an appointment with the service for general dermatology. Relevant health promotion and information on support groups will be made available at all clinic waiting areas with additional verbal support offered by the staff if requested. Nationally accepted information is available for download from the British Association of Dermatologists website. All service providers will have a formal complaints procedure. All complaints will be managed as per the complaints procedures of the service provider and County Durham Primary Care Trust. 7. Continual Service Improvement/Innovation Plan Description of Scheme Milestones Expected Benefit Timescales Frequency of Monitoring Development of nurse led services and specialist nurse competencies Plan to be agreed between the commissioner and the service provider. Building capacity within the service and freeing up the non consultant clinical staff to undertake more complex work. Development of nurse skills and confidence. Improvement within 12 months of service commencement. Quarterly Development of general practice education through phased rotation of GPs into the service Plan to be agreed between the commissioner and the service provider. Building knowledge and expertise in general practice through the development of “resident experts” in each practice. Improve referral quality and maximise appropriate treatment in a primary care setting. Implementation of first phase of rotation within 6 months of service commencement. Quarterly Page 14 of 25
  15. 15. 8. Baseline Performance Targets – Quality, Performance & Productivity Performance Indicator Indicator Threshold Method of Measurement Frequency of Monitoring Quality Relevant Vital Signs VSA01, VSA03 VSA04B VSB15 Incidence of Healthcare Acquired Infections NHS reported waits for elective care – Non admitted Self reported experience of patients / users Target: zero reported incidents. Maximum 18 week wait from referral to treatment for 95% of non- admitted patients. To be agreed at a Clinical Review meeting between commissioner and provider. PCT will implement an audit of HCAI control and request a remedial action plan. Via the agreed mechanism prescribed in the contract. Patient satisfaction surveys, verbal feedback, incidents and complaints information. Monthly reporting of incidence to the PCT. As defined in the contract. To review patient satisfaction at least every six months at specific times agreed with the commissioner. Service User Experience Reducing Barriers and Inequalities Provision of a high quality, patient focused Dermatology and/or Skin Surgery Service. Improved access to services. To be agreed at a Clinical Review meeting between commissioner and provider but to include: Recurring incidents of the same type. Failure to investigate a complaint or incident. DNA rate of less than 1%. Where services are directly bookable, zero adverse advice line reports (TAL) (also known as Slot Issues). Patient satisfaction surveys, verbal feedback, incidents and complaints information. Clinical governance reports. Reported DNA rate via activity minimum data set. Data received through choose and book activity reporting. To review patient satisfaction at least every six months at specific times agreed with the commissioner. Incidents to be reported immediately to the commissioner. Continuous monitoring of incidents to identify any patterns. Monthly. Weekly. Page 15 of 25
  16. 16. Service / Pathway Efficiency Increasing follow-up to first attendance ratios Monitoring of follow-up to first attendance ratios Number of patients referred on to consultant in secondary care. Number of patients treated by the service (by clinician type) DNA rates. Monthly. Outcomes Conditions treated successfully Reduce failed treatments. Failed treatments recorded and discussed at clinical quality meetings. At least every six months. Performance & Productivity Improving Productivity To provide a service which will be delivered in the most appropriate setting for (the severity of) the patients condition, by the most appropriate clinician. To develop dermatological skills in general practice (section 7). Any positive growth in referral numbers to secondary care dermatology. Failure to agree a rotation of GPs into the service Monitored through MDS. Monitored through information into the clinical quality meeting. Monthly At least every six months. Access Improved access to services. Where services are directly bookable, zero adverse advice line reports (TAL) (also known as Slot Issues). Data received through choose and book activity reporting. Weekly. Page 16 of 25
  17. 17. 9. Activity 9.1 Activity Activity Performance Indicators Method of measurement Baseline Target Threshold Frequency of Monitoring Until the service model is proposed through an Any Willing PCT Provider (AWPP) application (i.e. scope of the service to be provided, and skill mix available), it is not possible to accurately estimate the activity plans (and associated costs) for the service. In accordance with the AWPP route, the PCT will not guarantee a minimum level of income or activity to any provider. 10. Currency and Prices 10.1 Currency and Price Basis of Contract Currency Price Thresholds Expected Annual Contract Value Cost per attendance (Inclusive of entire service costs including, for example, staff costs, accommodation, prescribing, consumables, disposable instruments and sterilisation). A detailed breakdown can be provided in support of the application. Tariffs for first and follow-up appointments: £ per first attendance £ per follow-up Tariff structure may be split further to reflect staff level (consultant, GPwSI, specialist nurse) £ To be proposed by the provider at application None. Under AWPP the commissioner cannot guarantee a minimum level of activity and therefore cannot guarantee that clinic appointments will be filled. Not applicable under AWPP Page 17 of 25
  18. 18. APPENDIX 1 MINOR SURGERY, DERMATOLOGY AND SKIN SURGERY TIERED MODEL FOR COUNTY DURHAM AND DARLINGTON Page 18 of 25 MINOR SURGERY (DES or COMMUNITY GP / GPSI SKIN SURGERY SERVICE) EXCLUSIONS OR PRIOR APPROVAL Suspicion of Melanoma or SCC REFER AS 2 WEEK RULE BCC of head and neck Rash with systemic disturbance in any age group Extensive rashes of diagnostic uncertainty in any age group Suspected connective tissue disorders Cutaneous vasculitis Acne requiring isotretinoin where workup is complete Moderate or severe psoriasis that may need phototherapy or 2nd line drug therapy Moderate to severe eczema that may need immunosuppressant drugs or phototherapy Allergic contact dermatitis Alopecia with: Significant scarring Unresolving alopecia areata Significant psych upset Keloid scars not responding to treatment Photodermatoses Arterial or mixed aetiology leg ulcers Nail disease: Acute, inflammatory Hyperhydrosis no responding to topical treatment Resistant cases of hidradenitis suppurativa Congential lesions – vascular or pigmented Second opinion for any rash or lesion from Tier 2 for diagnosis or management BCC low risk (below neck) * Rashes of diagnostic uncertainty Inflammatory disorders not responding to GP treatment, e.g. lichen planus Acne not responding to GP treatment or requiring workup for isotretinoin Mild to moderate psoriasis for treatment principally with topical therapies Mild to moderate eczema for treatment with topical therapies, and supervision by nurses / health visitors Troublesome red face Alopecia – localised alopecia areata Keloid scars Venous ulcers not responing to community treatment Nail dystrophy Hidradenitis suppurativa Benign lesions: Symptomatic seborrhoeic keratoses Pyogenic granulomata Dermatofibromata Changing lesions for diagnosis unless suspect melanoma or SCC Patients referred from secondary care for follow-up * All BCC low risk (below neck) MUST be triaged by either a Consultant Dermatologist or GPSI in Dermatology prior to any minor surgical procedure. (Lower rate) Keratin horn Skin lesions causing pain / trauma, e.g. large skin tags, chronic infection / sinuses Foreign Body removal Skin tags around eyelids Painful warts for cryotherapy Incision / excision biopsy Punch biopsy Actinic / solar keratoses for cryotherapy or biopsy Seb warts (keratoses) giving symptoms Endocervical polyps (Upper rate) Toe nail resection (consider podiatry referral) Toe nail ablation (consider podiatry referral) Excision of sebaceous / pilar / epidermoid cysts Lipomata Pyogenic granuloma Foreign Body removal complicated Chondrodermatitis nodularis helicis Meibomian cyst Xanthelasmata Incision and drainage of abscess EXCLUDED CONDITIONS The PCT will NOT fund the treatment of any of the following conditions unless in the unusual circumstance the lesion is causing pain or psychological distress: Small skin tags Naevi for cosmetic reasons Seb warts (keratoses) asymptomatic Spider naevi Dermatofibromata Molluscum contagiosum Viral warts hands and feet Haemangiomata LASER TREATMENT Requests for laser treatment must receive prior approval from the PCT before referral: Facial/neck port wine stains: Refer for assessment as soon as possible after birth The following strawberry naevi: Affecting functionally important areas such as orifices where obstruction may occur Any lesion complicated by bleeding or ulceration Significant facial telangiectasia resulting from rosacea or a connective tissue disorder Rhinophyma Latrogenic pigmentation e.g. following minocycline therapy Facial hirsuties: Due to underlying hormonal disease Causing significant psych disturbance Unresponsive to local/cosmetic measures Large xanthelasmata Acne scarring: Disfiguring Pitted, atrophic SECONDARY CARE DERMATOLOGY SERVICE COMMUNITY DERMATOLOGY SERVICE
  19. 19. APPENDIX 2 Provision for Assurance in relation to Criminal Records Bureau requirements and safeguarding arrangements relating to services commissioned by NHS Co Durham and NHS Darlington. NHS organisations must carry out criminal record checks for the appointment and ongoing employment of all eligible individuals in the NHS. For NHS County Durham and NHS Darlington, eligible individuals engaged in the delivery of all commissioned services both NHS and non NHS, including any new contracts issued, must comply with the NHS Employment Check Standards generally and the criminal records checks as outlined in the document Criminal Record Checks, in particular. These are available at These standards are mandatory for all applicants for NHS positions (prospective employees) and staff in ongoing NHS employment. This includes permanent staff, staff on fixed-term contracts, temporary staff, volunteers, students, trainees, contractors and highly mobile staff supplied by an agency. Trusts and other contractors appointing locums and agency staff must ensure that their contractors or providers comply with these standards. These standards replace previous NHS Employers guidance on safer recruitment and outline the employment checks NHS organisations must carry out. A written statement of compliance with these standards and undertaking to comply with any additional standards which may be introduced by NHS Employment Check Standards will be required prior to the commencement of the service. Particular attention is drawn to the new Vetting & Barring scheme launched 12th October 2009 and Contractors, providers and employers must familiarise themselves with the additional new requirements under the Safeguarding Vulnerable Groups Act (2006) and the launch of the Vetting & Barring Scheme which came into partial force from the12th October 2009. For the avoidance of doubt for new contracts, NHS Co Durham and NHS Darlington will require evidence of satisfactory CRB status for all those working with patients whether in a paid or voluntary capacity. For individuals not working with patients for CRB purposes, but undertaking a regulated activity within the new vetting and barring scheme, a CRB check will be required. Anyone working with patients and/or undertaking or accountable for regulated activity will be required to be checked. Anyone not checked cannot work with patients/undertake the regulated activity. Evidence of CRB clearance will be sought by the commissioner who may require the provider to provide additional information. It is now a criminal offence for individuals barred by the Independent Safeguarding Authority to work or apply to work with children or vulnerable adults in a wide range of posts - including most NHS jobs, Prison Service, education and childcare. Employers also face criminal sanctions for knowingly employing a barred individual across a wider range of work; The three former barred lists (POCA, POVA and List 99) are being replaced by two new ISA-barred lists; Employers, local authorities, professional regulators and other bodies have a duty to refer to the ISA, information about individuals working with children or vulnerable adults where they consider them to have caused harm or pose a risk of harm. New employees and those changing jobs in regulated activity do not need to start applying for ISA-registration until July 2010 and ISA-registration does not become mandatory for these workers until November 2010. All other staff will be phased into the scheme from 2011. Contractors must not employ anyone who appears on any of the lists currently held by either the Department of Children, Schools and Families (formerly the DfES) or the Department of Health, showing that the individual is barred from working with children and/or vulnerable adults under the Protection of Vulnerable Adults Act (PoVA) or Protection of Children Act (PoCA). Contractors and providers are also required to provide evidence of how their staff receive safeguarding training for vulnerable groups. If a contractor or provider receives information that might place the safety of any individual patient or service user at risk, the commissioner must be notified within one working day and advised of the circumstances and the actions taken by the contractor or provider to safeguard service users. Concerns relating to the safeguarding of children must be reported to the Designated Nurse for Safeguarding for NHS Co Durham and NHS Darlington and for adults to the Director of Nursing for NHS Co Durham and NHS Darlington. The contractor or provider will also provide a written report to the commissioner within 5 working days detailing the incident, documenting actions taken and the results of any investigation. The PCT as commissioner may decide to investigate the incident and providers must comply with the PCT serious untoward incident policies and processes. From time to time NHS Co Durham and NHS Darlington may request written assurance, whether by way of provision of CRB check details or otherwise as they ie the commissioner may determine, that any eligible individual engaged in delivering commissioned services continues to comply with the legal employment check requirements and safeguarding arrangements set out above. Page 19 of 25
  20. 20. APPENDIX 3 Part A MINIMUM DATA SET REQUIREMENTS Data item No. Field Names Data Item Section 15000201 Provider Code Care Contact Activities 15000200 Service Code Care Contact Activities 15000202 Commissioner Code Care Contact Activities Demographics 15000010 NHS Number Person 15000014 Date of Birth Person 15000020 Gender Person 15000016 Postcode Person Usual Place of residence 15000022 Employment Status Person 15000017 Registered practice code Person 15000023 Ethnicity Person 15000024 Religion Person 15000027 Disability status Person Care Plan 15000151 Comprehensive Care Plan in place Care Plans 15000156 Care Plan Start Date Care Plans 15000157 Care Plan End Date Care Plans Referral Details 15000052 Referral date Service Referral 15000053 Referral time Service Referral 15000056 Referral source Service Referral 15000060 Referral type Service Referral 15000067 Reason referral rejected Service Referral 15000101 Pre-existing long-term condition Needs Assessment Appointment Details 15000219 Site code Care Contact Activities 15000223 Appointment date Care Contact Activities 15000224 Appointment Time Care Contact Activities 15000205 Appointment Type Care Contact Activities 15000216 Contact Method Care Contact Activities 15000228 Activity Attendance Care Contact Activities 15000207 Care Professional identifier Care Contact Activities 15000103 Diagnosis 1 Needs Assessment 15000104 Diagnosis 2 Needs Assessment 15000104 Diagnosis 3 Needs Assessment 15000210 Procedure 1 Care Contact Activities 15000211 Procedure 2 Care Contact Activities 15000409 Clinical Outcome Care Outcome 15000409 Clinical Outcome Care Outcome Page 20 of 25
  21. 21. Onward Referral Details 15000305 Onward referral to organisation Onward Referral 15000306 Onward referral to service Onward Referral 15000201 Provider Code 15000200 Service Code 15000202 Commissioner Code Page 21 of 25
  22. 22. APPENDIX 3 Part B MINIMUM DATA SET VALUES LIST Data item No. Field Names Values List Demographics 15000010 NHS Number 15000014 Date of Birth 15000020 Gender 0 - Not Known 1 - Male 2 - Female 9 - Not specified 15000016 Postcode Usual place of residence Own home Residential care home Nursing home Supported living Prison Other 1500022 Employment status Employed Unemployed and Seeking Work Students who are undertaking full (at least 16 hours per week) or part-time (less than 16 hours per week) education or training and who are not working or actively seeking work Long-term sick or disabled, those who are receiving Incapacity Benefit, Income Support or both Homemaker looking after the family or home and who are not working or actively seeking work Not receiving benefits and who are not working or actively seeking work Unpaid voluntary work who are not working or actively seeking work Retired from paid work Not Stated (PERSON asked but declined to provide a response) 15000017 Registered practice code 15000023 Ethnicity A - British B - Irish C - Any other White background D - White and Black Caribbean E - White and Black African F - White and Asian G - Any other mixed background H - Indian J - Pakistani K - Bangladeshi L - Any other Asian background M - Caribbean N - African P - Any other Black background R - Chinese S - Any other ethnic group Z - Not stated 15000024 Religion Source - NHS Data Dictionary 15000027 Disability status Behaviour and Emotional Page 22 of 25
  23. 23. Hearing Manual Dexterity Memory or ability to concentrate, learn or understand (Learning Disability) Mobility and Gross Motor Perception of Physical Danger Personal, Self Care and Continence Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc) Sight Speech Other No Registered DISABILITY Not Stated (PERSON asked but declined to provide a response) Care Plan 15000151 Comprehensive Care Plan in place 15000156 Care Plan Start Date 15000157 Care Plan End Date Referral Details 15000052 Referral date 15000053 Referral time 15000056 Referral source A&E Department Allied Health Professional Carer Education Service Employer General Medical Practitioner Health Visitor Home Office Hospice Hospital Local Authority Social Services Residential or Nursing Home School Self Referral Specialist Nurse Walk In Centres Wheelchair Service Youth Services Other 15000060 Referral type Routine Urgent Two Week Wait 15000067 Reason referral rejected Cancelled - Referral entered in error Discharged - Admitted elsewhere Discharged - Maximum improvement Discharged - Medically Unfit for Treatment Discharged - Moved out of Area Discharged - Patient Died Discharged - Patient Requested Discharge Discharged - Patient Unsuitable for Treatment Discharged - Patient`s Health Deteriorated Page 23 of 25
  24. 24. Discharged - Referred to Other Specialty Discharged - Refused to be Seen Discharged - Service No Longer Available Discharged - Termination / miscarriage Discharged - Treatment Complete Discharged - Unable To Make Contact with Patient Rejected - Duplicate Referral - Patient already under treatment for the same problem Rejected - Inappropriate Referral - The referral is inappropriate for the services offered by the organisation Rejected - Incomplete Referral - Incomplete Information on the referral Rejected - Service Unavailable - The service for which the person is being referred is no longer provided by the organisation 15000101 Pre-existing long-term condition Appointment Details 15000219 Site code 15000223 Appointment date 15000224 Appointment Time 15000216 Contact Method 01 - Face to face 02 - Telephone 03 - Letter 04 - E-mail 05 - Fax 06 - Home Visits 07 - Message via Carer 08 - Message via Reception 09 - Message via Relative 10 - Out Of Hours 11 - SMS 12 - Other 99 - Not Applicable 15000205 Activity Type Initial Follow Up 15000228 Activity Attendance Activity / Intervention completed Cancelled by Patient - advance warning given Cancelled by Provider Did not attend - no advance warning given Not applicable - Appointment occurs in the future 15000207 Care Professional identifier 15000103 Diagnosis 1 ICD10 code 15000104 Diagnosis 2 ICD10 code 15000104 Diagnosis 3 ICD10 code 15000409 Clinical Outcome Significantly healed Partially healed Marginally healed No change Degenerated 15000409 Clinical Outcome As above 15000210 Procedure 1 OPCS Code 15000211 Procedure 2 OPCS Code Onward Referral Details 15000305 Onward referral to organisation Page 24 of 25
  25. 25. 15000306 Onward referral to service Page 25 of 25