Microsoft word - drug monitoring les 2012 - coastal only.doc

Practice Name:
Practice Address:
Specification for a Locally Enhanced Service (LES)
Drug Monitoring in Primary Care 2012/13

Introduction
This LES is based on the National Enhanced Service framework for near patient testing and takes into
account the local situation.
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 services
to be provided. 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.
Background
The treatment of several diseases, is increasingly reliant on medicines that, whilst clinically effective,
need regular blood and other monitoring, due to the potentially serious side effects that these
medicines can occasionally cause and to monitor effectiveness. It has been shown that the incidence
of side effects and risk to patients and prescriber can be reduced significantly if this monitoring is
carried out in a well-organised way. This particularly applies to medicines with
Responsibility for follow-up transfer from secondary care to primary care This Locally Enhanced Services takes account of the historic case of need for a LES, and reflects the
increasing responsibility being requested of primary care prescribers, and is intended to complement,
but not duplicate, prescribing responsibility covered under GMS QOF. This LES is an important
vehicle to support appropriate use of medicines that would otherwise require continued prescribing
responsibility by specialists and consequent increased secondary care out-patient activity and costs.
Aims
The drug monitoring service is designed to be one in which:
(i) therapy should only be started for recognised indications for specified lengths of time
(ii) maintenance of patients first stabilised in the secondary care setting should be properly controlled
thereafter
(iii) the service to the patient is convenient
(iv) the need for continuation of therapy is reviewed regularly
(v) the therapy is discontinued when appropriate
(vi) the use of resources by the National Health Service is efficient.
Drug Monitoring in CWS

This LES will apply to all patients who are prescribed the medicines listed in primary care regardless
of the departments in secondary care involved in the initiation of therapy.
This LES will encourage prescribing to continue in primary care in recognition of the advantages of the
entire prescribing record being held in primary care. However, it is expected that primary care teams
will implement systems to further ensure safe prescribing. Responsibility for therapeutic monitoring of
medicines initiated in secondary care remains in secondary care.
The primary care phlebotomy element of monitoring these medicines has been included in the LES for
phlebotomy services.
Immunosuppressants
(NB excluding post-renal transplant patients under care of BSUH for whom prescribing of
immunosuppressants has been repatriated to BSUH)
It is recognised that certain medicines used post transplant may have a narrow therapeutic margin,
may carry a high risk of side-effects, need a high level of support for critically important patient
compliance and /or require a complicated monitoring regime. Such medicines are initiated in tertiary
care and may have been agreed as suitable for prescribing by specialist clinicians only, therefore may
not have agreed shared care guidelines in place. Where appropriate, arrangements may be made for
a local secondary care clinician to continue prescribing of such medicines. However, as the tertiary
care centres are often distant, it can be impractical for patients to collect repeat prescriptions from
them, or local secondary care clinicians may not be able to assume prescribing responsibility. GPs
may therefore decide to prescribe such medicines in order to assure continuity of care for patients.
Monitoring, however, remains the responsibility of the tertiary care centre.
The PCT recognises that this situation is imperfect but that, in practical terms, it is likely to continue.
Therefore these medicines are included in this LES to ensure that prescribing GPs have a system in
place to check that satisfactory monitoring does occur. Communication is usually made from tertiary to
primary care by letter and should contain details of drug monitoring where appropriate. If this is not
occurring in an acceptable manner, we would encourage GPs to contact the tertiary care centre to that
effect.
Shared care medicines
The PCT recognises that some ‘amber’ medicines, initiated in secondary care but prescribed in
primary care under shared care arrangements, are appropriate for payments under this LES as an
element of monitoring is the responsibility of primary care to ensure safe prescribing. In these cases
these medications are included and the shared care guideline, where available, is published on the
GP website.
Service Outline

This local enhanced service will fund a shared care drug monitoring service in respect of the following
specified medicines:
DMARDS – the following medicines, and only where an element of monitoring is the responsibility of
primary care
a) Methotrexate
b) Leflunomide
c) Gold preparations
d) Penicillamine
e) Ciclosporin
f) Sulphasalazine
26/06/2012
g) Hydroxychloroquine h) Azathioprine Immunosuppressants a) Tacrolimus (oral) b) Sirolimus c) Mycophenolate d) Ciclosporin Shared care medicines with an element of monitoring responsibility in primary care a) somatropin b) dronedarone Enhanced Services Group may add to or remove medications from the above list from time to time depending on changes to monitoring requirements and use of new therapies. Any changes to this list will be notified to GP practices. Clinical responsibilities will be clearly defined between primary and secondary care, where practicable, as follows: PRIMARY CARE RESPONSIBILITIES Initiation of appropriate therapy only in line with any current NICE TAG. Normally to prescribe initial 28 days of medication, and to ensure all information To inform the consultant if unwilling to enter relevant to transfer of prescribing responsibility into shared care arrangements according to To ensure that all newly treated patients (and / or their carers) receive appropriate education and advice regarding their medicine. This should include written information where appropriate To provide and monitor repeat prescriptions and take responsibility for ongoing monitoring To ensure and take responsibility for baseline of parameters that relate to safe prescribing and ongoing monitoring and act on the results (mainly blood tests). A demonstrable system appropriately and to ensure that any blood should be in place to ensure that prescribing is reviewed by the GP if there is no record of communicated promptly and in full to the the fact that monitoring has taken place within the agreed time-scales. To record any changes in therapy in the communication from secondary care To monitor the patient’s overall health and well being and to report any adverse drug reactions Clinical review at appropriate agreed intervals. or interactions to the appropriate secondary care clinician. To review the appropriateness of prescribing Notify the GP of patient’s failure to attend for for patients who have not been seen by a
Shared Care

Shared care guidelines are available, or will be available in due course, for each medicine on the LES
giving more information and details of monitoring requirements. These shared care arrangements are
a result of collaboration between primary and secondary care through the CWS CCG medicines
management team, Area Prescribing Committee and the relevant specialists.
Register

Practices should be able to produce and maintain an up-to-date register of all shared care drug
monitoring service patients, indicating patient identifier, date of birth, medicine prescribed, the
indication for treatment, monitoring undertaken and most recent hospital appointment.
Individual management plan and monitoring

Secondary / tertiary care should 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, together with any other relevant patient information.
•
National guidance about monitoring required at baseline, during initiation, during maintenance, actions required when faced with an abnormal result, other relevant information, and BNF-listed significant drug interactions is available on the National electronic Library for Medicines website www.nelm.nhs.uk/en/NeLM-Area/Evidence/Drug-Monitoring/Suggestions-for-Drug-Monitoring-in-Adults-in-Primary-Care/?query=primary+care+monitoring&rank=100 (large pdf reference document – recommend search on generic name or drug group). If unsure of action required when faced with an abnormal result, it is acceptable for GP to seek advice from or refer patient back to consultant or specialist team. • link to national monitoring guidance will also be published on the CWS GP website by end June www.westsussexgp.com/index.php?menuItem=21&area=0&page=137 Prescribers should also refer to the relevant Summary of Product Characteristics published by the manufacturer at www.medicines.org.uk/emc (search on generic name) Where a prescribed medicine is covered by an Effective Shared Care Arrangement (ESCA), prescribers should also refer to the relevant ESCA published on GP website (NB – ESCAs will be
published by end June 2012)
Professional links

All involved have a responsibility to work together with other professionals when appropriate. Any
health professionals involved in the care of patients covered by this LES 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, side-effects necessitating cessation of therapy,
etc 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 received the necessary training and professional development, and have the required
competencies and skills to provide the primary care responsibilities.
Annual review

All practices involved in the scheme may be asked to provide information which could include:
(a) details of training, education and professional development relevant to the drug monitoring service
(b) details of the clinical standards used for the control of the relevant condition, e.g. NICE
(c) assurance that any staff member responsible for prescribing must have developed the necessary
skills to prescribe safely.
(d) audit of activity claimed under the service specification
Untoward events
It is a condition of participation in this LES that practitioners will give 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 medicine(s) in question.
We encourage all participants to report any ‘near miss’ event through the normal local clinical
governance reporting procedure.
Costs
Each practice contracted to provide this service will receive:
£6.08 per patient monitored (NB including patients on more than one medicine covered by this LES)
and on the register at the end of each month (equivalent to £72.96 per patient per annum)
Claiming
Claims should be made monthly via the multi-claim form.
Termination

This Enhanced Service may be terminated by either the PCT or the contractor through the service of 3
months written notice.
Application
Practice Name:

GP Provider Application for Locally Enhanced Scheme : Drug Monitoring in Primary Care
2012/13
How will you meet the aims of the scheme?
Briefly describe the service to be provided and facilities available.
Will providing this service adversely affect the practice’s ability to provide essential or additional
services?
Who will be providing the service?
Do you have evidence of appropriate staff qualifications, if appropriate?
How will you ensure staff providing the service remain suitably qualified?
How will you monitor and audit service provision (refer to any requirements within the scheme).
Please outline any other details relevant to your ability to provide this service
Monitoring/audit information for this scheme can be sent to the Commissioning Support Service
Primary Care Team from 1st April 2012 until 31st March 2013
The practice has understood the terms of the scheme and is seeking to provide a service on this basis. If commissioned the practice will adhere to the terms of the scheme. Signed: ____________________________________ As GP principal representative of the practice Date: _____________________________________
Breach
Breach of conditions of this contract will be referred to the CCG Enhanced Services Group.

Signed on behalf of Practice………………………………………….
Name of Practice ………………………………………………………
GP Name (Print)……………………………………………………
GP Signature…………………………………………………………. GP Name (Print)…………………………………………………… GP Signature…………………………………………………………. GP Name (Print)…………………………………………………… GP Signature…………………………………………………………. GP Name (Print)……………………………………………………
GP Signature………………………………………………………….
Signed on behalf of the PCT

……………………………………………………………. Date …………………………
Ruth Frost
Lead for Primary Care Contracting and Commissioning on behalf of NHS Sussex (CSU)

N.B. This form must be completed in full for your application to be accepted and will be used as part of the
monitoring information for the scheme.

Source: http://www.westsussexpct.nhs.uk/domains/westsussex.nhs.uk/local/media/images/medium/drug_monitoring_les_2012___coastal_only.pdf