SCHEDULE 2 – THE SERVICES

A. Service Specifications

Mandatory headings 1 – 4: mandatory but detail for local determination and agreement Optional headings 5-7: optional to use, detail for local determination and agreement. All subheadings for local determination and agreement

Service Specification

No.

Service Think Pharmacy Urgent Palliative Care Medicines Service

Commissioner Lead NHS Vale Royal CCG

Provider Lead Superintendent Pharmacist

Period 1 April 2014 to 31 March 2017

Date of Review

1.1 National/local context and evidence base Patients who have been assessed as entering the last days of life require access to a set range of palliative care medicines in anticipation of need. Community pharmacists included in this service guarantee to continuously stock the medicines in the palliative care formulary so that patients can be assured of supply when required. The stock held for the Think Pharmacy Urgent Palliative Care Medicines Service should be over and above the core stock holding, and the CCGs agree to reimburse contractors should the medicines be held beyond their expiry date. This service:

Supports patients and their carers to access medicines that may be required for palliative care purposes in a location close to their home (or preferred place of death)

Avoids unnecessary hospital admissions where the sole purpose of admission is to access appropriate medicines

Supports pharmacies to hold palliative care medicines in stock

Provides assurance to commissioners that patients who require palliative care medicines will have access to the medicines during core hours from specified locations.

2. Outcomes

2.1 NHS Outcomes Framework Domains & Indicators

Domain 1 Preventing people from dying prematurely

Domain 2 Enhancing quality of life for people with long-term

conditions

Domain 3 Helping people to recover from episodes of ill-health or

following injury

Domain 4 Ensuring people have a positive experience of care

Domain 5 Treating and caring for people in a safe environment

and protecting them from avoidable harm

2.2 Local defined outcomes

To improve access across the geographical area covered by the commissioners (NHS South Cheshire CCG, NHS Vale Royal CCG and NHS Eastern Cheshire CCG) for patients and health care professionals to Palliative Care medicines when they are required within normal pharmacy opening hours.

To guarantee continuous availability of formulary stock from named pharmacies for patients and health care professionals who require immediate / urgent access to palliative care medicines.

3. Scope

3.1 Aims and objectives of service

To continuously hold the range and quantity of medicines specified by the palliative care formulary and to dispense these in response to NHS prescriptions presented for the total number of hours the pharmacy is open

To have a process in place which ensures that all new staff, are aware of commissioned services provided by the pharmacy and maintain continuity of service during and after staff changes.

3.2 Service description/care pathway

The service provider must order and continuously hold the range and quantity of medicines specified by the formulary and will dispense these in response to NHS prescriptions presented. See Appendix 1

The service provider will provide the service for the total number of hours the pharmacy is open.

The stock for this service should be in addition to any stock holding the service provider would usually stock.

Expiry dates for this stock should be monitored to prevent waste; short dated stock should be rotated with the service provider’s usual stock holding.

Dispensed or date expired stock for this service must be replaced immediately.

The Commissioners will reimburse the cost of stock specifically purchased for this service that cannot be used and has reached its expiry date. This will be done by completing the Expired Stock Claims form. See Appendix 3

In the event of any significant availability issues concerning products required to be

kept in stock for this service the serviced provider must contact the Commissioner.

The service provider must telephone the next nearest service provider in advance

to ensure that they are able to dispense the prescription before signposting a patient or carer.

The contract payment is for provision of a Think Pharmacy Urgent Palliative Care Medicines Service Payments will be made as follows.

- £200 annual fee for providing the service irrespective of the number of prescription items dispensed.

- The fee will be paid as a lump sum on the receipt of an annual declaration from the service provider of their intent to continue the service from the named community pharmacy

- Claims will be made and paid annually on submission of the declaration and invoice in Appendix 4.

Accreditation

Any registered pharmacist may dispense palliative care medicines on receipt of a valid prescription. Suggested training that may support this service. CPPE Care of the terminally ill – communicating with patients open learning.

Standard Operating Procedure

The service provider will have a Standard Operating Procedure (SOP) / protocol which specifically details the operational delivery of the Think Pharmacy Urgent Palliative Care Medicines Service in accordance with this specification.

The service provider must ensure that all staff working in the pharmacy have relevant knowledge, are appropriately trained and operate within protocols / SOPs, this includes understanding when to recommend the service to clients and using sensitive client-centred communication skills.

The SOP / protocol should be reviewed at least every two years or before if circumstances dictate. Each review should be documented and the SOP / protocol subject to version control. Staff must read, date and sign the SOP/protocol after a review.

Changes to procedure must be highlighted within the SOP / protocol for special attention.

The Standard Operating Procedure / protocol must be available to the commissioner if requested.

Record Management

Records maintained in association with this service must be available to the commissioner on request.

Service Continuity

It is the responsibility of the service provider to have a process in place that ensures that all new staff and locums are aware of the Think Pharmacy Urgent Palliative Care Medicines Service and must maintain continuity of service during and after staff changes.

The service provider has a responsibility to ensure that all staff members provide the service strictly in accordance with the service specification and Standard Operating Procedures.

If concerns are raised regarding the continuity of service provision the commissioner reserves the right to instigate discussions with the contractor, which could lead to termination of the contract

Complaints

The service provider must have a complaints procedure that complies with Local Authority Social Services and National Health Service complaints (England) Regulations 2009.

Complaints directly linked to the quality of this service must be reported to the commissioner.

3.3 Population covered Patients resident within the geographical area covered by NHS Eastern Cheshire CCG, NHS South Cheshire CCG and NHS Vale Royal CCG who present a prescription for palliative care medicines are eligible for inclusion in the service. The total population is estimated to be as follows:

204,000 in Eastern Cheshire

176,000 in South Cheshire

103,000 in Vale Royal.

Equality and Diversity

The service provider must comply with the requirements of the Equality Act 2010, and will not treat one group of people less favourably than others because of age, disability, gender reassignment, marriage or civil partnership, race, religion or belief, sex or sexual orientation.

It is the responsibility of the service provider to make reasonable adjustments to meet the individual needs of their patients. Where providers are able to identify a cohort of patients for whom reasonable adjustments may be required, they should discuss this with the Commissioner.

3.4 Any acceptance and exclusion criteria and thresholds Community pharmacies must hold an NHS contract for the provision of Pharmaceutical Services. Pharmacies will be selected for inclusion in the service to provide sufficient coverage in each town /locality so that patients are not unduly inconvenienced when seeking to have their prescriptions for palliative care medicines dispensed.

3.5 Interdependence with other services/providers Community pharmacies are expected to liaise with out of hours / urgent care providers and general practice to facilitate access to the palliative care formulary medicines.

4. Applicable Service Standards

4.1 Applicable national standards (eg NICE) Supply of ALL medicines must be in accordance with the Human Medicines Regulations 2012. The commissioner and the commissioned service provider recognize that this service specification and/or associated recorded information may be subject to Freedom of Information Requests (FOI). Each party shall comply with any such Freedom of Information requests received, in accordance with the Freedom of Information Act 2000 legal obligations. The service provider shall comply with the requirements of the Health and Safety at Work Act 1974, the management of Health and Safety at Work Regulations 1999 and any other acts, regulation, orders or rules of law pertaining to health and safety. 4.2 Applicable standards set out in Guidance and/or issued by a competent body

(eg Royal Colleges) The Think Pharmacy Urgent Palliative Care Medicines Service may only be provided by

Pharmacists with a current registration with the General Pharmaceutical Council from premises that hold a current contract to supply NHS Pharmaceutical Services.

4.3 Applicable local standards The Think Pharmacy Urgent Palliative Care Medicines Service shall be available during ALL of the community pharmacy provider’s core opening hours. Any medicines dispensed from the Palliative Care stock should be immediately replaced to ensure continuity of supply.

5. Applicable quality requirements and CQUIN goals

5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D])

Not Applicable

5.2 Applicable CQUIN goals (See Schedule 4 Part [E]) Not Applicable

6. Location of Provider Premises

The Provider’s Premises are located at:

7. Individual Service User Placement

Appendix 1

Central and Eastern Cheshire Palliative Care Formulary

Emergency Palliative Care Drugs – Listed service providers in Central and Eastern Cheshire will always have this range and quantity of drugs in

stock

Health Care Professionals can access help via. the 24hr advice line numbers for Specialist Palliative Care Advice

South Cheshire and Vale Royal: 01606 551246 Eastern Cheshire: 01625 666999

Drug Form available Quantity Main indications in acute situation

Commoner acute

side-effects

Dosage

Diamorphine 5mg ampoule

10mg ampoule;

30mg ampoule;

100mg ampoule

5 ampoules

5 ampoules

5 ampoules

5 ampoules

Severe pain not controlled by weak opioid

Patient unable to take

morphine orally

Drowsiness (settles with time); nausea, vomiting (try metoclopramide or haloperidol); unsteadiness

Confusion, hallucinations (tolerance does not occur, reduce or change drug)

If no previous opioid –

5mg 4 hourly & prn, or 30mg/24h SC in syringe driver (half if frail)

If changing from oral morphine - 1/3 total daily morphine dose, given SC via syringe driver

The prn dose is 1/6 of 24h diamorphine dose

Drug Form available Quantity Main indications in acute situation

Commoner acute

side-effects

Dosage

Morphine Sulphate

10mg ampoule;

30mg ampoule;

10 ampoules

10 ampoules

Severe pain - to be used as an alternative to diamorphine if diamorphine is not available

Drowsiness (settles with time); nausea, vomiting (try metoclopramide or haloperidol); unsteadiness

Confusion, hallucinations (tolerance does not occur, reduce or change drug)

If no previous opioid –

5mg-10mg 4 hourly & prn,

or 30mg-45mg/24h SC in syringe driver (half if frail)

If changing from oral morphine - 1/2 total daily oral morphine dose, given SC via syringe driver

If changing from SC diamorphine – 1.5 times total daily SC diamorphine dose, given SC via syringe driver

The prn dose is 1/6 of 24h morphine dose

Oramorph® 10mg/5ml

oral solution

100mg/5ml concentrated oral

solution

2 x 100ml

1 x 30ml

Severe pain not controlled by weak opioid

Drowsiness (settles with time); nausea, vomiting (try metoclopramide or haloperidol); unsteadiness

Confusion, hallucinations (tolerance does not occur, reduce or change drug)

Initially 10mg (5mg if frail) as needed 2 hourly, or depending on previous morphine dose

Breakthrough dose = 1/6 of regular 24h total morphine dosage

Drug Form available Quantity Main indications in acute situation

Commoner acute

side-effects

Dosage

Diclofenac 100mg suppository 10 supps Inflammatory pain, especially bone pain, musculoskeletal pain

Occasional bronchospasm; nausea; dyspepsia

50-100mg stat;

150mg-200mg/day in divided doses

Cyclizine 50mg in 1ml ampoule

5 ampoules Nausea caused by pharyngeal stimulation, visceral distension or deformation, vestibular disturbance, raised intracranial pressure

Drowsiness, anti-muscarinic effects (blurred vision, palpitations, palpitations, arrhythmias, dry mouth, constipation, heartburn, urinary retention)

50 mg SC prn tds;

100-150mg/24h SC via syringe driver (may be increased to 300mg if needed and tolerated)

Haloperidol 5mg in 1 ml ampoule

5 ampoules a)Anti-emetic for chemical

or toxic causes

b)Agitation or acute

confusional state

Extra-pyramidal - including tardive dyskinesia, sedation, dry mouth, neuroleptic malignant syndrome

a) 1.5-5mg SC stat dose up to 6 hourly or 5-15mg per 24h via syringe driver

b) 1.5-5mg SC stat, then 5-30mg SC od to bd, or over 24h via syringe driver

Metoclopramide

10mg in 2ml ampoule

10 ampoules Nausea and vomiting due to gastric irritation or impaired emptying (stasis)

Extrapyramidal effects; neuroleptic malignant syndrome; sedation in high doses

10mg stat SC every 3-4 hours or 30-60mg/24h SC via syringe driver (up to 100mg on specialist advice)

Levomepromazine (methotrimeprazine)

25mg in 1 ml ampoule

10 ampoules Nausea and vomiting (broad spectrum)

Severe agitation, psychosis

Sedation;

postural hypotension;

extra-pyramidal

5-25mg SC once or twice a day in divided doses, or via syringe driver (stepwise to 300mg/24h if tolerated)

Midazolam 10mg in 2ml ampoule

10 ampoules Terminal agitation

Myoclonus

Seizures

Sedation; hypotension 2.5-10mg SC stat (10-20mg SC or slowly IV for repeated seizures); then 20-60mg/24h via syringe driver (up to 100mg/24h has been used)

Drug Form available Quantity Main indications in acute situation

Commoner acute

side-effects

Dosage

Diazepam Rectal Solution

4mg/ml 2.5ml tube = 10mg

5 x 10mg tubes

Hyoscine Butylbromide

20mg in 1ml ampoule

5 ampoules Bowel colic obstruction

Moist, noisy breathing if patient is comatose

Anticholinergic (blurred vision, palpitations, palpitations, arrhythmias, dry mouth, constipation, heartburn, urinary retention); does not cross blood-brain barrier

20mg stat, then 60mg/24h via syringe driver, increasing to 120mg if needed (occasionally to 300mg in obstruction)

Glycopyrronium Bromide (Robinul

®)

200micrograms/ml ampoule

10 x 1ml ampoules

Bowel colic

Moist, noisy breathing if patient is comatose

Anticholinergic (blurred vision, confusion, palpitations, palpitations, arrhythmias, dry mouth, constipation, heartburn, urinary retention)

200-400micrograms SC repeated as needed every 3 hours

600-1200micrograms per 24 hours by SC infusion

Drug Form available Quantity Main indications in acute situation

Commoner acute

side-effects

Dosage

Dexamethasone

2mg tablet 50 tablets Pain & symptom relief from raised intracranial pressure, spinal cord compression, liver capsule pain, nerve compression

Relief of pressure in superior vena caval obstruction, stridor, spinal cord compression

Adjunct to anti-emetic in resistant nausea

Acute - mental disturbance, impaired glucose tolerance, masking of symptoms of acute infection

8 to 16mg orally once daily

For acute spinal cord compression - where intervention is appropriate, give 16mg once to twice daily & admit urgently

Water for Injections

10ml ampoule 2 x 10 ampoules

Making up of diamorphine and diluting to correct volume for syringe driver

Appendix 2 Think Pharmacy Urgent Palliative Care Service Providers in Central and Eastern Cheshire

TOWN / AREA PHARMACY NAME & ADDRESS CONTACT N0 OPENING HOURS

ALSAGER LLOYDS PHARMACY

25 Lawton Road Alsager ST7 2AA

01270 882049

(Tel. & Fax)

Mon-Fri 8.15am-6.30pm

Sat 9.00am-5.00pm

CONGLETON

Co-Op Healthcare Ltd

2 Mill Street Congleton CW12 1AB

01260 273200

(Tel. & Fax.)

Mon-Sat 9.00am-5.30pm

Sat 9.00am-1.00pm

CO-OP HEALTHCARE Ltd

1 Park Lane

Congleton CW12 3DN

01260 280810 (Tel.)

01260 273209 (Fax.)

Mon-Fri 8.45am-6.30pm

Sat 9.00am-1.00pm

Tesco In Store Pharmacy

Barn Road

Congleton

CW12 1LR

01260 205247(Tel) Mon 8. 00am – 10.30pm

Tue- Fri 6.30am – 10.30pm

Sat 6.30am – 10.00pm

Sun 10.00am – 4.00pm.

Boots UK ltd

Barn Road

Congleton CW12 1LR

01260 276977 (Tel)

01260 271057 (Fax)

Mon– Fri 8.00am – 12.00pm Sat 8.00am - 10.00pm

Sun 10.00am – 4.00pm

CREWE ASDA IN-STORE PHARMACY

Victoria Centre

Crewe CW1 2PT

01270 258271

(Tel. & Fax)

Mon 8.00am-11.00pm

Tues-Fri 7.00am-11.00pm

Sat 7.00am-10.00pm

Sun 10.00am-4.00pm

BOOTS UK LTD

56-58 Market Street

Crewe CW1 2EX

01270 212252 (Tel.)

01270 251319 (Fax)

Mon-Sat 9.00am-5.30pm

Tesco In Store Pharmacy

Vernon Way

Crewe CW1 2DD

01270 416647 (Tel)

01270 416449 (Fax)

Mon 8.00am – 10.30pm

Tue – Fri 6.30am – 10.30pm

Sat 6.30am – 10.00pm

Sun 10.00am – 16.00pm

Boots UK Ltd

Unit 12

01270 254702 Mon-fri 8.00am-12.00midnight

Grand Junction Retail Parl

Crewe CW11 2RP

Sat 8.000am -10pm

Sun 11.00am – 5.00pm

DISLEY CO-OP HEALTHCARE Ltd

11 Fountian Square

Disley SK12 2AB

01663 762048

(Tel. & Fax)

Mon,Tues,Thur,Fri

9.00am-6.00pm

Wed, Sat 9.00-1.00pm

HANDFORTH CO-OP HEALTHCARE Ltd

110 Wilmslow Road

Handforth SK9 3ES

01625 523945

(Tel. & Fax)

Mon,- Fri 8.30am – 6.30pm

Sat 9.00am-1.00pm

TESCO IN-STORE PHARMACY

Kiln Croft Lane

Handforth SK9 3HL

0161 2517347

(Tel. & Fax)

Mon-Sat 9.00am-9.00pm

Sunday 10.00am-4.00pm

HOLMES CHAPEL

LLOYDS PHARMACY

39-41 London Road

Holmes Chapel CW4 7AP

01477 532347 (Tel.)

01477 535517 (Fax)

Mon-Fri 8.30am-7.00pm

Sat 8.30am-5.00pm

KNUTSFORD MANNINGS CHEMIST

38 Princess Street

Knutsford WA16 6BN

01565 633078

(Tel. & Fax)

Mon-Fri 9.00am-7.00pm

Sat 9.00am-5.30pm

Boots

64 King Street

Knutsford WA16 6DT

01565 633114 (Tel)

01565 631350 (Fax)

Mon – Sat 9.00am – 5.30pm

Sun 11.00am – 4.00pm

MACCLESFIELD

ASSURA PHARMACY

Waters Green Medical Centre

Sunderland Street

Macclesfield SK11 6JL

01625 664405 (Tel.)

01625 619984 (Fax)

Mon-Sat 7.00am-10.00pm

Sun `` 10.00am – 8.00pm

LLOYDS PHARMACY

46-48 Charlotte Street

Macclesfield SK11 6JB

01625 424895

(Tel. & Fax)

Mon-Sat 8..00am-10.30pm

Sun 9.30am-10.30pm

THE WESTON PHARMACY

5-6 Weston Square

01625 423465 (Tel.)

Mon,Tues,Thur,Fri

9.00am-6.00pm

Earlsway

Macclesfield SK11 8SS

01625 613836 (Fax) Wed, Sat 9.00am-5.30pm

Tesco In Store Pharmacy

Hibel Road Macclesfield SK10 2AB

01625 603449 (Tel and Fax)

Mon – Sat 8.00am – 8.00pm

Sunday 10.00am – 4.00pm

Sainsbury’s Pharmacy

61 Cumberland Street

Macclesfield

SK10 1BJ

01625603906 (tel-fax Mon - 8:00 am – 11:00 pm

Tues – Fri 7:00 am – 11:00 pm

Sat 7 00 am – 10:00 pm

Sun 10:00 am – 4:00 pm

MIDDLEWICH ROWLANDS PHARMACY

24 Lewin Street

Middlewich CW10 9AS

01606 837604

(Tel. & Fax)

Mon ,Tue, Thur, Fri

09.00am – 13.00pm & 13.20pm – 18.00pm

Wed

09.00am – 13.00pm & 13.20pm – 17.30pm

Sat

09.00am – 13.00pm & 13.20pm – 16.30pm

NANTWICH CO-OP PHARMACY

Church View Primary Care Centre

Beam Street Nantwich CW5 5NX

Tel : 01270 627565

Fax : 01270 624176

Mon – Fri

08.00am – 18.30pm

SAINSBURY’S IN-STORE PHARMACY

Middlewich Road

Nantwich CW5 6PH

01270 618591 (Tel.)

01270 618591 (Fax)

Mon-Fri 7.00am-11.00pm

Sat 7.00am-10.00pm

Sun 10.00am-4.00pm

NORTHWICH DAVENPORT CARMICHAEL LTD

76 Runcorn Road

Barnton CW8 4EY

01606 74671 (Tel.)

01606 782400 (Fax)

Mon-Fri 9.00am-6.00pm

Sat 9.00am-1.00pm

ROWLANDS PHARMACY 01606 74261 Mon – Fri

09.00am – 13.00pm &

299 Chester Road

Hartford

Northwich CW8 1QL

(Tel. & Fax) 13.20pm – 18.00pm

Sat 09.00am – 13.00pm

TESCO IN-STORE PHARMACY

Manchester Road

Northwich CW9 5LY

01606 311449

(Tel. & Fax)

Mon-Sat 8.00am-8.00pm

Sun 10.00am-4.00pm

Sainsburys Supermarkets Ltd

Venables Road

Northwich

CW9 5RT

01606 314509 Mon & Sat 700AM-10.00PM

Tue –Fri 7.00am-11pm

Sun 10.00am – 4.00pm

POYNTON ROWLANDS PHARMACY

67 Park Lane

Poynton SK12 1RD

01625 873955 (Tel.)

01625 850734 (Fax)

Mon – Fri 09.00am – 13.00pm & 13.20pm – 18.30pm

Sat 09.00am – 13.00pm & 13.20pm – 17.30pm

PRESTBURY D K WOOD LTD

The Village Pharmacy

Unicorn House

Prestbury SK10 4DG

01625 829216

(Tel. & Fax)

Mon,Tues,Wed,Fri

9.00am-5.30pm

Thur 9.00am-6.00pm

Sat 9.00am – 13.00pm

SANDBACH CO-OP HEALTHCARE Ltd

Ashfields Primary Care Centre

Middlewich Road Sandbach

01270 762205 (Tel.)

01270 750372 (Fax)

Mon-Fri 8.30am – 19.00pm

WILMSLOW Boots UK Ltd

Within Waitrose Store

5 Church Street

Wilmslow SK9 1AY

01625 530876

(Tel. & Fax)

Mon-Thur 9.00am- 20.00pm

Fri 09.00am – 21.00pm

Sat 9.00am- 20.00pm

Sun 10.00am-4.00pm

WINSFORD

ASDA IN-STORE PHARMACY

Dene Drive

Winsford CW7 1BD

01606 596410 (Tel.)

01606 596411 (Fax)

Mon 08.00am – 23.00pm

Tue – Fri 07.00am – 23.00pm

Sat 07.00am – 22.00pm

Sun 10.00am – 16.00pm

CO-OPERATIVE CHEMIST

Winsford Health Centre

Dene Drive Winsford CW7 1AT

01606 592543

(Tel. & Fax)

Mon-Fri 8.30am-6.30pm

APPENDIX 3

Emergency Palliative Care Medicines Support Service Date Expired Stock Claim Form

Service Provider

Address

Expired stock

Drug Form Quantity Purchase cost Purchased from

Claims will be paid within 28 days of submission of this form accompanied by a purchase invoice. Send completed claims form to:

CCG Geographical location of Pharmacy service provider

Invoice details

NHS Vale Royal CCG

Northwich Winsford (and surrounding areas)

NHS Vale Royal Clinical Commissioning Group 02D Payables K955 Phoenix House Topcliffe Lane Wakefield

WF3 1WE

NHS South Cheshire CCG

Alsager Crewe Haslington Middlewich Nantwich Sandbach (and surrounding areas)

NHS South Cheshire Clinical Commissioning Group 01R Payables K945 Phoenix House Topcliffe Lane Wakefield WF3 1WE

NHS Eastern Cheshire CCG

Alderley Edge Bollington Congleton Disley Handforth Holmes Chapel Knutsford Macclesfield Poynton Wilmslow (and surrounding areas)

NHS Eastern Cheshire Clinical Commissioning Group 01C Payables K935 Phoenix House Topcliffe Lane Wakefield WF3 1WE

Appendix 4.

Think Pharmacy Urgent Palliative Care Medicines Service Declaration and Self Assessment Monitoring Document: 2014-17

Community pharmacies providing an Urgent Palliative Care Medicines Service will be reimbursed at £200 per year, irrespective of the volume of items / prescriptions dispensed. The fee will be paid as a lump sum on receipt of an annual self assessment service monitoring declaration and declaration of intent to provide the service from the named community pharmacy for the proceeding 12 month period.

1. Service Monitoring, self assessment declaration

The pharmacy has the following procedures/processes in place (Please circle as

appropriate)

A standard operating procedure (SOP) or guidance which specifically details the overall delivery of this service. Y N

Completed and documented review of the SOP/guidance annually. Y N

Trained all staff to follow the service delivery specification. Y N

A training log that details training given to staff. Y N

A process in place that ensures that all new staff are aware that this service is proved by the pharmacy and continuity of service is maintained during and after staff changes. Y N

A copy of the latest service specification, in the pharmacy for reference. Y N

Summarise any issues the pharmacy has encountered with the delivery of the service

2. Provision of Service, Declaration of intent

I confirm that the named pharmacy will continuously provide an Urgent Palliative Care Service in accordance with the Service Specification for the period 2014-2015

I confirm that by agreeing to provide the Service this form acts as an Invoice for payment.

Pharmacy

Full address

Signed

Print

Date

Position

Please complete the Self Declaration and submit this form for payment. Claims will be paid within 28 days of submission of this form accompanied by a purchase invoice. Send completed claims form to:

CCG Geographical location of Pharmacy service provider

Invoice details

NHS Vale Royal CCG

Northwich Winsford (and surrounding areas)

NHS Vale Royal Clinical Commissioning Group 02D Payables K955 Phoenix House Topcliffe Lane Wakefield

WF3 1WE

NHS South Cheshire CCG

Alsager Crewe Haslington Middlewich

NHS South Cheshire Clinical Commissioning Group 01R Payables K945 Phoenix House

Nantwich Sandbach (and surrounding areas)

Topcliffe Lane Wakefield WF3 1WE

NHS Eastern Cheshire CCG

Alderley Edge Bollington Congleton Disley Handforth Holmes Chapel Knutsford Macclesfield Poynton Wilmslow (and surrounding areas)

NHS Eastern Cheshire Clinical Commissioning Group 01C Payables K935 Phoenix House Topcliffe Lane Wakefield WF3 1WE