Revised for: 1 April 2014 Appendix 2.4 SERVICE SPECIFICATION FOR THE PROVISION OF PRIMARY CARE PRESCRIBING FOR DRUG MISUSE IN DORSET ONLY Dorset County Council Dorset Procurement, Level 3, North East Wing, County Hall, Colliton Park, Dorchester, Dorset, DT1 1XJ
DORSET COUNTY COUNCIL Page 2 of 11 1. INTRODUCTION 1.1. This Service Specification sets the requirements for the provision of a Service for Primary Care Prescribing for Drug Misuse (formerly known as Shared Care, and which is referred to as Primary Care Prescribing within this document) in Dorset. 1.2. The Service shall provide treatment for problematic drug users using a range of treatment options identified as part of a best practice approach as outlined in the Drug Misuse and Dependence Guidelines on Clinical Management 2007 Department of Health: http://www.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf 1.3. Primary Care Prescribing in this document is defined as: the joint treatment of people with problematic drug use by a GP, Pharmacy and workers within the Primary Care Support Service in partnership with community drug and alcohol workers. Primary Care Prescribing shall be available to Service Users that are stable on their substitute prescription and meet the Criteria for Primary Care Prescribing. 1.4. Primary Care Prescribing Services are an essential means of managing and supporting clinicians and Service Users in the delivery of safe and effective services, especially where prescribing may be necessary. Primary Care Prescribing is supported by the Local Medical Committee as an essential means of maintaining standards for clinical governance and risk management. 2. BACKGROUND 2.1. Drug misuse and its complications, pervade every part of society and social classes and are a problem found across the whole country. 2.2. The number of drug users in the general population is estimated to be in the region of 250,000, with 6% of the adult population in Dorset dependent on drugs. 2.3. Based on current estimates it is likely that almost every General Practitioner (GP) will have patients registered with them who use illegal drugs problematically. 2.4. Primary Care prescribing for drug misuse is a vital component of the drug-treatment system in Dorset and offers many benefits to Service Users including improved access, treatment by their own GP, and treatment in the community. 2.5. It can be observed that there is an increasing preference by drug misusers to receive care in a Primary Care setting within the community wherever possible as it reduces the feelings of stigmatisation (Department of Health, 1999). 2.6. There is also evidence to suggest that Service Users receiving treatment from their GP, expressed greater satisfaction with it and reported a better emotional state in comparison to Service Users receiving treatment from a specialist drug service (Speed et al, 2000 in mistral and Smith, 2001). 3. AIMS AND OBJECTIVES OF THE SERVICE / SERVICE OUTCOMES 3.1. The aim of the Service is to support Service Users through the joint participation of specialists and GPs in the planned delivery of care for Service Users with drug misuse problems, informed by an exchange of information beyond routine referral and discharge letters.
DORSET COUNTY COUNCIL Page 3 of 11 3.2. The overall aim of treatment is: 3.2.1. To enable Service Users to engage in a process of change whereby their drug taking and risky behaviour ceases to have an impact on their lifestyle; 3.2.2. To enable Service Users to assume their human rights and responsibilities and have the opportunity to develop a drug free life and integrate into society. 3.3. The key outcomes of the Service are: 3.3.1. Reduction in the number of drug related deaths; 3.3.2. Reduction in illicit or non-prescribed drug use; 3.3.3. Improvement in physical and mental well-being; 3.3.4. Reduction/cessation of criminal activity; 3.3.5. Reduction in the risk of prescribed drugs being diverted onto the illegal market; 3.3.6. Cessation of injecting behaviour and of the sharing of injecting; 3.3.7. Relative abstinence from illegal drug use; 3.3.8. An opportunity to promote recovery and abstinence 3.4. This shall be achieved through: 3.4.1. Continuing the Service Users prescription of substitute opiate drugs in a community setting; 3.4.2. Minimising the spread of HIV, Hepatitis B and C and other blood-borne diseases through testing and vaccination in conjunction with the Specialist Provider; 3.4.3. Providing accurate, up-to-date and non-judgemental health advice relevant to Service Users; 3.4.4. Providing advice and information to the Service Users family or carers; 3.4.5. Treating other problems associated with problematic drug use including anxiety, insomnia, co-morbidity with alcohol or mental illness according to the NHS Standards for Better Health Framework and relevant NICE Guidance 3.4.6. Regularly reviewing the Service User s progress and/or changing treatment needs; 3.4.7. Enabling Service Users to engage in a process of change whereby their drug taking and risky behaviour ceases to have an impact on their lifestyle; 3.4.8. Improving physical and emotional well-being; 3.4.9. Improving personal and social functioning; 3.4.10. Reducing the risk of prescribed drugs being diverted onto the illegal drug market; 3.4.11. Reducing the risk of injecting behaviour; 3.4.12. Ensuring that Service Users abstain from illegal drug use; 3.4.13. Encouraging multi-disciplinary working and collaboration in the provision of services within the community for Service Users; 3.4.14. Increasing opportunities to promote recovery and abstinence; 3.4.15. Increasing the number of Service Users successfully recovering from drug dependence; 3.4.16. Ensuring that the general health needs of the Service User are met. 4. DESCRIPTION AND SCOPE OF SERVICE 4.1. The Provider shall ensure that GP s operating as part of the provision of this Service are actively involved in the management of their registered patients who are also Service Users of the Specialist Drug and Alcohol service and undertake appropriate prescribing for their needs when required. 4.2. The Provider shall offer appropriate prescribing for its own registered patients who are Service Users of the local drug treatment system. Appointments with the specialist provider shall be assisted by the Providers Prescribing GP. The Provider may also offer Primary Care Prescribing to neighbouring surgeries patients where the surgeries do not
DORSET COUNTY COUNCIL Page 4 of 11 provide this Service or where the needs of Service Users are best met by another prescribing practice. 4.3. The Provider shall have in place the following elements: 4.3.1. An accurate register of Service Users 4.3.2. A sequential review as appropriate 4.3.3. Safe and secure practices, appropriate for the provision of the Service 4.3.4. A good knowledge of, and effective liaison with, local drug services and other agencies, including non-statutory services 4.3.5. Effective approaches to joint working with local pharmacies, primary care drug support workers, social services (including the Child Protection Service) and local mental and clinical health teams. 4.4. The Provider s Prescribing General Practitioner shall: 4.4.1. Jointly develop and co-ordinate the care of drug users in conjunction with the local specialist drug treatment provider and develop associated practice guidelines; 4.4.2. Have up to date knowledge of local detoxification procedures; 4.4.3. Treat dependent Service Users utilising additional support as appropriate this support shall be from, for example, nurses with specialist interest, staff within specialist drug treatment providers including non-medical prescribers. This shall include the prescribing of substitute (opiate and non-opiate) drugs or antagonists using best practice as outlined in the Department of Health s drug misuse clinical guidelines or equivalent; 4.4.4. Ensure that prescribing takes place within a context in which the co-existing physical, emotional, social and legal problems are addressed as far as possible; 4.4.5. Participate in audits of prescribing practice; 4.4.6. Act as a resource to practice colleagues in the care of Service Users; 4.4.7. Demonstrate participation in additional training and continuing professional development this should be commensurate with the level of service provision excepted of a clinician in line with any national or local guidance to meet the requirements of revalidation; 4.4.8. Maintain the safety and training of clinical and non-clinical Employees 4.4.9. Provide care for Service Users outside their own registered list (if agreed with the local specialist drug treatment providers to look after such Service Users). The Provider shall have an effective means of communication with the registered GP. 4.4.10. Encourage Service Users to take up the opportunity of screening in line with national screening programmes; 4.4.11. Provide on-going assessment of substitute prescribing in partnership with the local specialist drug treatment provider; 4.4.12. See Service Users regularly, as directed by the local specialist drug treatment provider; 4.4.13. Be legally and clinically responsible for prescribing from their Practice; 4.4.14. Approve any non-medical prescribers clinical management plans associated with Service Users within the Service; 4.4.15. Ensure that all scripts generated as part of the Service are through the Practice / Surgery clinical systems as far as this is practicable; 4.4.16. Discuss with the local specialist drug treatment provider any changes in prescription and substance use; 4.4.17. Keep appropriate clinical records and record attendance; 4.4.18. Look after the general health needs of the Service User; 4.4.19. Provide effective advice on contraception where appropriate and/or undertake referral to appropriate local services; 4.4.20. Arrange for vaccinations to meet Service User needs;
DORSET COUNTY COUNCIL Page 5 of 11 4.4.21. Inquire about other drug related problems and provide support or referral as appropriate; 4.4.22. Agree with the local specialist drug treatment provider who will inform the Pharmacist when a Service User is no longer entitled to receive a prescription; 4.4.23. Undertake referral to infectious diseases services, where necessary; 4.4.24. Support the management of screening, immunisation and treatment for blood borne viruses in conjunction with the local specialist drug treatment provider. Referrals 4.5. An individual must meet the following criteria to be eligible to be referred to the Service: 4.5.1. Aged 18 or over 4.5.2. Have drug misuse issues 4.5.3. Resident within the Dorset County Council area or registered with a Dorset GP Practice 4.6. All referrals into the Service shall be via the local specialist drug treatment provider. The local specialist drug treatment provider shall undertake a Comprehensive Assessment, Risk Assessment and Recovery Management Plan for each Service User. 4.7. Each Service User shall have a signed and agreed treatment contract in place which the Provider, Service User and local specialist drug treatment provider shall abide by. 4.8. The Provider shall ensure that the Service User: 4.8.1. Is advised on admission to the Practice Providers Service that there are rules and boundaries and what these are; 4.8.2. Is advised on the anticipated length of stay within the drug treatment service; 4.8.3. Is advised on the ethos of the Service; 4.8.4. Is informed that there is a complaints procedure within the Service and a copy will be given. 4.8.5. Gives their consent for their personal information to be shared with their GP and the local specialist drug treatment provider 4.9. The Provider has the right to refuse a Service User admission to the Service where it is unable to meet the needs of the Service User, or if admission will be detrimental to the Service and/or other Service Users attending the Service. 4.10. Service Users may have a variety of Support Workers/Key Workers allocated from a variety of agencies. The local specialist drug treatment provider will be the overall Care Co-ordinator and be the lead professional on treatment decisions i.e. referrals to other/alternative provision, housing referrals etc. 4.11. The Provider in partnership with the local specialist drug treatment provider, shall ensure that any ethnic, religious or cultural needs identified in the individual Service Users Recovery Support Plan or Comprehensive Assessment are met. 4.12. If a Service User expresses a view to either the Provider or the local specialist drug treatment provider that the placement is not meeting their needs, a review shall be held led by the Primary Care Support Service in partnership with the Providere and Service User. A placement shall not be amended in any way without the consent of these parties. 4.13. Once a placement has been made and the Service commenced for the Service User, the Provider is responsible for the provision of the Service in line with the Service Specification.
DORSET COUNTY COUNCIL Page 6 of 11 Controlled Drugs Governance 4.14. The prescribing in primary care will be scrutinised by the commissioning organisation s identified controlled drugs lead. Any irregularities in prescribing will be challenged with the practice and may be referred to the NHS England Local Area Team Accountable Officer and/or raised with the Local Intelligence Network. 4.15. All incidents related to controlled drugs within the Service shall be reported to the organisational controlled drug lead and shared with the Consultant responsible for Drugs and Alcohol. Prevention of Opiate Overdose/Drug Related Deaths 4.16. The Provider s Prescribing General Practitioners shall specifically warn Service Users about the risk of overdose, with particular attention to instances: 4.16.1. When alcohol is taken at the same time; 4.16.2. Where tolerance may have reduced if doses are missed; 4.16.3. When other drugs are taken at the same time; 4.16.4. Post detoxification. 4.16.5. Service users should be advised of basic first adi and to seek medical attention if they are with someone suspected or overdosing. 4.17. Service Users shall be warned that as little as 25 mg of methadone could be fatal in a non-tolerant individual. 4.18. Service Users shall be advised that as little as 5mg of methadone can be fatal to a small child. The importance of keeping all medicines, in a locked cabinet/container and out of reach of children must be repeatedly emphasised. Portable lockable cabinets are available for Service Users from the local specialist drug treatment provider. 4.19. To reduce the risk of overdose, when prescribing methadone, Prescribing General Practitioners and Primary Care Support Workers shall ensure that: 4.19.1. Appropriate efforts are made to reduce diversions on to the illegal market, e.g. through good prescribing practice; 4.19.2. No more than one weeks supply should be prescribed/dispensed as a single instalment except in exceptional specific circumstances e.g.: going away on holiday. 4.19.3. If a Service User is going on holiday, prescriptions can be arranged in advance and sent to pharmacies locally (when in UK). This shall be done in line with the Dorset Clinical Commissioning Group policy. Termination of Provision of the Service to Individual Service Users 4.20. Termination of a Primary Care Prescribing Recovery Plan shall be considered by the Provider in the following circumstances: 4.20.1. There has been a complete breakdown in the treatment process through repeated non-attendance to appointments and/or continuous non-compliance with the treatment plan. In this case, the Service User shall be discharged from the Service. 4.20.2. The Service User breaks the contract through displaying violence towards Surgery Employees, other Service Users or Community Pharmacist staff. 4.21. In such cases, this should be agreed in liaison with the Service User s Key worker so that alternative support arrangements can be put in place where possible to support the individual in an attempt to re-arrange them.
DORSET COUNTY COUNCIL Page 7 of 11 4.22. The Provider s Prescribing General Practitioner shall specifically advise Service Users about the risk of blood borne viruses (BBV) and harm minimisation. To reduce the risk of BBV, the Prescribing General Practitioner shall ensure that Service Users are aware of the availability of needle exchange and sexual health services where appropriate. Key Links 4.23. The Provider s Prescribing General Practitioner must have access to appropriate pharmaceutical advice and support. 4.24. The Provider shall maintain appropriate links with local area teams of the National Commissioning Board and Clinical Commissioning Group(s) concerned with best practice in prescribing and medicines optimisation. This may include, but is not exclusive to Local Intelligence Networks for Controlled Drugs, Local Professional Networks and Medicines Optimisation Networks. 4.25. On admission to hospital / prison of a Service User, the Provider shall co-operate with requests for prescribing information from health professionals in order that accurate drug history and prescribing can take place during the admission. 5. QUALITY STANDARDS 5.1. The Provider shall: 5.1.1. Demonstrate compliance with all relevant national standards for service quality and clinical governance including compliance with the NHS Standards for Better Health Framework and relevant NICE Guidance. 5.1.2. Ensure that all premises and equipment used for the provision of the Service are at all times suitable for the delivery of the Service and sufficient to meet the reasonable needs of Service Users. 5.1.3. Demonstrate that an effective system of clinical governance and quality assurance is in place. 5.1.4. Ensure that a robust system of reporting adverse incidents or serious untoward incidents is in place. All incidents shall be documents, investigated and followed up with appropriate action. Any lessons learnt from incidents shall be shared across the Providers organisation and with the Purchaser. 5.1.5. Ensure that all lines of professional and clinical responsibility and accountability are clearly identified. 5.1.6. Develop and follow infection control policies that are compliant with national and local guidelines. All infection control, decontamination measures and sterilisation of equipment must meet the standards within the Health and Social Care Act (2008) and its associated Code of Practice for Health and Social Care on the Prevention and Control of Infections and related guidance. 5.1.7. Ensure that relevant safety alerts and Medical & Healthcare Products Regulatory Agency (MHRA) notices are circulated to staff and acted upon where necessary. 5.1.8. Ensure that a process is in place for any member of the professional team to raise concerns in a confidential and structured way. 5.1.9. Demonstrate a robust information service/source for Service Users and review regularly based on Service User feedback. 5.1.10. Ensure that Service Users are able to contribute to the planning of their own care and that opportunities for feedback are easily available. 5.1.11. Ensure that treatment, care and information provided is culturally appropriate and is available in a form that is accessible to people who have additional needs, such as people with physical, cognitive or sensory disabilities, and people who do not speak or read English.
DORSET COUNTY COUNCIL Page 8 of 11 5.1.12. Co-operate with any national or Dorset County Council led assessment of Service User experience. 5.1.13. Fully comply with the Pan-Dorset s Multi agency Safeguarding Adults Policy and the Pan Dorset LSCB Inter-Agency Procedures for Children and Young People. 5.1.14. Ensure that thorough recruitment and selection processes are in place which includes full tracking of previous employment history, checking of qualifications, two written references and Disclosure and Barring Service (DBS) checks. Training of Primary Care Prescribing GPs 5.2. The Provider shall: 5.2.1. Ensure that all GP s providing the Service shall have achieved or be working towards the RCGP Level 1 Certificate in Substance Misuse. 5.2.2. Ensure (and be able to demonstrate) that all GP s and Employees involved in the provision of the Service hold the relevant current qualifications and have undertaken CPD relevant to the Service. 5.2.3. Ensure that the level of training required for a GP providing the Service is identified in the GP s personal development plan, and be a part of the appraisal and revalidation process. Record Keeping 5.3. The Provider shall: 5.3.1. Ensure an appropriate record of activity is developed and maintained for audit and payment purposes and which meets the requirements of this Service Specification. 5.3.2. Ensure that every episode is recorded in the Lifelong Service User Record. 5.3.3. Ensure that the relevant information is shared with the local specialist drug treatment provider in a timely manner to enable them to update the Dorset Case Management System (HALO). Individuals Accompanying a Service User 5.4. The Provider shall make all individuals accompanying a Service User aware of their Visitor Confidentiality Policy. 5.5. The Provider has the right to exclude an individual accompanying a Service User if they threaten any of the Provider s Employees and/or a Service User or disturbs the smooth running of the Provider s premises. In such circumstances, the Purchaser must be notified in writing of the reasons for the exclusion. 6. CONTRACT MONITORING Monthly Performance Monitoring 6.1. The Provider, in partnership with the local specialist drug treatment provider, shall ensure that any information required by the National Drug Treatment Monitoring System and/or National Alcohol Treatment Monitoring System, on behalf of the Drug and Alcohol Action Team, is forward by the 8th of every month, after the local specialist drug treatment provider has authorised that submissions may begin. 6.2. The Provider shall submit quarterly activity data with their quarterly financial claim in respect of this Service Specification as follows: Number of Service Users receiving treatment under this contract that are registered with the practice; Number of Service Users receiving treatment under this contract that are unregistered with the practice.
DORSET COUNTY COUNCIL Page 9 of 11 Six Monthly Performance Monitoring 6.3. The Provider shall facilitate and work in collaboration with Primary Care Support Service to deliver the Service and meet the following performance targets. Activity data shall be submitted to demonstrate achievement of these or provide detail for explanation of any variance. 6.3.1. 100% of Service Users to commence within the Service within 3 weeks from point of referral and prescribed by the GP; 6.3.2. 100% of Services Users to have a Primary Care Prescribing Recovery Support Plan in place within 2 working days of entering into the Service provision or within 2 working days of their Recovery Support Plan Review in partnership with the Primary Care Support Service; 6.3.3. 100% of Service Users to be entered onto HALO and their records updated as required in partnership with the Primary Care Support Service; 6.3.4. 100% of Service Users to have their support reviewed in line with the Service Specification and their Recovery Support Plan regularly updated; 6.3.5. 100% of Service Users to receive an Enhanced Review in partnership with their Care Co-ordinator at least once a year; 6.3.6. 100% of submissions to the NDTMS / NATMS to be delivered within the timeframe in partnership with Primary Care Support Service; 6.3.7. 65% of Service Users to leave in a planned way; 6.3.8. 40% of individuals to leave successfully drug free or occasional user; 6.3.9. 100% of Service Users to have a TOP completed in line with the Dorset DAAT TOP Guidance and within the time frame specified; 6.3.10. 85% of Service Users to have reported an improvement in their health; 6.4. The Provider will produce the following information: 6.4.1. Number and nature of complaints; 6.4.2. Number and nature of compliments; 6.4.3. Outcomes of any Serious or Adverse Incidents; 6.4.4. Summary of any Service User feedback or Surveys; 6.4.5. Training undertaken by Provider s Staff. Direct Monitoring 6.5. The Drug and Alcohol Action Team reserve the right to carry out a Direct Monitoring visit during the Contract Period to look into: 6.5.1. Policies, Procedures, Written Plans and Strategies for the provision of the Service; 6.5.2. Provider s Employee Files; 6.5.3. Service User Files; 6.5.4. Informal talks with Service Users; 6.5.5. Informal talks with the Provider s Employees. 6.6. The Provider shall ensure that the necessary documentation, as detailed in this Service Specification, is maintained and made available to the Purchaser to enable the Service to be monitored and for the purpose of post payment verification. 6.7. The Purchaser may undertake a visit to the practice to inspect the provision of the Service and to ensure that the Provider is meeting the Service Specification. Quality Reporting 6.8. The following Quality Outcomes represent targets against which the Provider and Purchaser will monitor quality activity:
DORSET COUNTY COUNCIL Page 10 of 11 6.8.1. 100% of complaints received must be acknowledged within 5 working days of the complaint being received; 6.8.2. 100% of complaints received must be notified to the Purchaser within 7 working days of the complaint being received; 6.8.3. 100% of professionally trained members of the Provider s Employees are annually attending continuing professional development training/programmes; 6.8.4. 100% of the Provider s Managers are undertaking or have achieved an appropriate accredited management training programme 6.8.5. 100% of data submitted to the NDTMS/NATMS to be accurate. 6.9. In partnership with the local specialist drug treatment providers, Prescribing GPs will undertake an annual audit of Service Users who have been on substitute prescribing over 2 years to ensure that Service Users are working towards recovery. 6.10. The Provider shall participate in an audit of the Service provided if requested by the Purchaser. Audit will include as a minimum: 6.10.1. Number of Service Users who have a review of their general health, including blood pressure checks, cervical smears, contraception, smoking interventions and vaccinations; 6.10.2. Number of Service Users on chronic statement; 6.10.3. Number and outcome of investigations for any significant incident / untoward events; 6.10.4. Service User feedback on the Service. 6.11. The Provider shall submit the following information to the Purchaser on an annual basis: 6.11.1. Number of Service Users who entered the Service; 6.11.2. Number of Service Users who left the Service; 6.12. The Provider shall carry out and submit an Annual prescribing audit to enable the Purchaser to compare the activity from other Providers also delivering the Service. 7. SERVICE SPECIFICATION REVIEW 7.1. It is recognised within this Service Specification that the Service may be subject to change due to a range of national and local policy initiatives. For example, government guidance and legislation, industry professional standards, NICE Guidance, England or Dorset County Council Policy. 7.2. This Service Specification shall be reviewed annually taking into consideration a financial review of the Service, any service developments and/or changes in legislation. Three months notice will be given to the Provider of any significant changes which may impact on the service provided and will ensure sufficient transition arrangements are secured to ensure service continuity. Less significant changes may be made following an appropriate period of consultation with the Provider. 8. FINANCIAL INFORMATION Payment and Reimbursement Structure 8.1. An annual fee will be paid to the Provider per Service User in quarterly instalments based on activity. The fee is based on the pre October 2006 PCT configuration. 8.1.1. The annual fee shall be 262.49 which translates to a quarterly payment of 65.62 to be claimed per Service User.
DORSET COUNTY COUNCIL Page 11 of 11 Claims for Payment 8.2. Dorset County Council will make payments for claims submitted on a quarterly basis if the claim is received by the Team by 20 th of the month following the end of the quarter. 8.3. Dorset County Council will make payment in line with the payment for other public health services provided by the Provider. Providers must submit a quarterly claim using the electronic Local Authority Claims provided by Dorset, Dorset County Council. 8.4. In order to receive payment under this service, the Provider must: 8.4.1. make available any additional information/evidence that Dorset, Dorset County Council requires, in order to establish whether the Provider has fulfilled its obligation under the Contract arrangements; 8.4.2. make the returns required of it promptly and fully. This includes using the electronic Local Authority Claims provided and provision of audit data to coincide with the submission of the relevant quarter s payment claim; and 8.4.3. ensure that all information supplied is accurate. 8.5. No claims will be considered if they are submitted more than 1 quarter in arrears. 8.6. No claim should be submitted more than one month after the end of this agreement. 8.7. Dorset, Dorset County Council reserves the right to undertake post payment verification of any claim. 8.8. If the Provider breaches any of the conditions specified in this Service Specification, including the timescales for claiming and audit, the Purchaser may, in appropriate circumstances withhold payment of any or any part of, any payment that is otherwise payable. 8.9. It is the Provider s responsibility to ensure that payment claims are accurate. The Purchaser will not normally make any backdated payments in relation to inaccurate claims except at its discretion where the Provider can demonstrate exceptional circumstances.