module b – performance requirements – specification, quality

COMMUNITY BASED DERMATOLOGY SERVICE

SERVICE SPECIFICATION

---- OCTOBER 2010 ----

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MODULE B – PERFORMANCE REQUIREMENTS – SPECIFICATION, QUALITY AND PRODUCTIVITY

SECTION 1 – SPECIFICATION

Care Pathway/ServiceCommunity based dermatology services

Commissioner LeadAdrian Metcalf, Planned Care Policy Lead, NHS County Durham

Provider Lead

Period3 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.

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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.3. To ensure the sustainability of the 18 weeks target. 4. To provide care closer to home.

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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 NetworkPrimary Care Dermatology SocietyBritish 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 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.

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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 treatmentso 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.

The following sections provide the commissioner’s expectations of the possible staff groups involved in the service.

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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. 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.

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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).

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

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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. 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

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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 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.

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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, 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

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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. 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.

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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 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 NHS.net email address to receive discharge information.

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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

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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.

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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.

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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

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APPENDIX 1 MINOR SURGERY, DERMATOLOGY AND SKIN SURGERY TIERED MODEL FOR COUNTY DURHAM AND DARLINGTON

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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 neckRash with systemic disturbance in any age

groupExtensive rashes of diagnostic uncertainty

in any age groupSuspected connective tissue disordersCutaneous vasculitisAcne requiring isotretinoin where workup is

completeModerate 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 dermatitisAlopecia with:Significant scarringUnresolving alopecia areataSignificant psych upsetKeloid scars not responding to treatmentPhotodermatosesArterial or mixed aetiology leg ulcersNail disease:

Acute, inflammatoryHyperhydrosis no responding to topical

treatmentResistant cases of hidradenitis suppurativaCongential lesions – vascular or pigmentedSecond opinion for any rash or lesion from

Tier 2 for diagnosis or management

BCC low risk (below neck) *Rashes of diagnostic uncertaintyInflammatory disorders not responding to

GP treatment, e.g. lichen planusAcne not responding to GP treatment or

requiring workup for isotretinoinMild to moderate psoriasis for treatment

principally with topical therapiesMild to moderate eczema for treatment

with topical therapies, and supervision by nurses / health visitors

Troublesome red faceAlopecia – localised alopecia areataKeloid scarsVenous ulcers not responing to

community treatmentNail dystrophyHidradenitis suppurativaBenign lesions:

Symptomatic seborrhoeic keratosesPyogenic granulomataDermatofibromataChanging lesions for diagnosis unless

suspect melanoma or SCCPatients 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 hornSkin lesions causing pain / trauma, e.g.

large skin tags, chronic infection / sinuses

Foreign Body removal Skin tags around eyelidsPainful warts for cryotherapyIncision / excision biopsyPunch biopsyActinic / solar keratoses for cryotherapy

or biopsySeb warts (keratoses) giving symptomsEndocervical polyps

(Upper rate)Toe nail resection (consider podiatry

referral)Toe nail ablation (consider podiatry

referral)Excision of sebaceous / pilar /

epidermoid cystsLipomataPyogenic granulomaForeign Body removal complicatedChondrodermatitis nodularis helicisMeibomian cystXanthelasmataIncision and drainage of abscess

EXCLUDED CONDITIONSThe 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 tagsNaevi for cosmetic reasonsSeb warts (keratoses) asymptomaticSpider naeviDermatofibromataMolluscum contagiosumViral warts hands and feetHaemangiomata

LASER TREATMENTRequests 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 occurAny lesion complicated by bleeding or

ulcerationSignificant facial telangiectasia resulting from

rosacea or a connective tissue disorderRhinophymaLatrogenic pigmentation e.g. following

minocycline therapyFacial hirsuties:

Due to underlying hormonal diseaseCausing significant psych disturbanceUnresponsive to local/cosmetic measures

Large xanthelasmataAcne scarring:DisfiguringPitted, atrophic

SECONDARY CARE DERMATOLOGY SERVICE

COMMUNITY DERMATOLOGY SERVICE

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 http://www.nhsemployers.org/. 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.

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http://www.nhsemployers.org/

APPENDIX 3 Part A

MINIMUM DATA SET REQUIREMENTS

Data item No. Field Names Data Item Section15000201 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

placeCare 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



15000210 Procedure 1 Care Contact Activities

15000211 Procedure 2 Care Contact Activities

15000409 Clinical Outcome Care Outcome

15000409 Clinical Outcome Care Outcome

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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

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APPENDIX 3 Part B

MINIMUM DATA SET VALUES LIST

Data item No. Field Names Values ListDemographics 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

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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

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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



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

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15000306 Onward referral to service

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