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SCHEDULE 2 – THE SERVICES

A. Service Specifications Service Specification No.

Service Community Physiotherapy

Commissioner Lead Dr. Rakesh Raja (WSCCG);

Provider Lead

Period 1 December 2014 – 30 November 2017

Date of Review

1. Population Needs

1.1 National/local context and evidence base Musculoskeletal (MSK) disorders are the fifth highest area of spend in the NHS, consuming £4.2bn in 2008/9, and increasing each year. MSK conditions also have a significant social and economic impact, with up to 60% of people who are on long-term sick leave citing MSK problems as the reason, and patients with MSK forming the second largest group (22%) receiving incapacity benefits. The Pain in Europe 2003-NFO group reported that at least 11.5% of the UK population suffers from chronic MSK pain, with the most frequent cause being arthritis. The most common reason that people visit their GP is pain, (ref Elliot AM, Smith BH, Penny KI et al, The epidemiology of chronic pain in the community. Lancet 1999:354:1248-1252) and is reported to be the main reason for 29% of patient visits in primary care. For the locality, there are therefore a significant number of patients for whom there is a need for a service in a primary care setting that supports those living with chronic MSK pain. There are over 200 MSK conditions affecting millions of people, including all forms of arthritis, back pain and osteoporosis. The World Health Organisation, (WHO) and Bone and Joint Health strategies Project (2005 cited by the Department of Health) identified that:

• Up to 30% of all GP consultations are for MSK complaints • MSK problems are cited by 60% of people on long term sickness. 40% of the over 70’s have

Osteoarthritis (OA) of the knee • An estimated 8-10 million of the UK population have arthritis, including 1 million adults

under 45 and 70% of 70 year olds • 80% of people report low back pain at some point in their life • Trauma caused by road traffic accidents (RTAs) will be the third highest ranked cause of

disability by 2020 The socio-economic impact is significant and predicted to rise. This Service Specification draws on guidance from Towards the Best Together (East of England SHA 2008) and the Lord Darzi NHS next stage review – High Quality for All (2008) and the Musculoskeletal Framework (DH 2006). Local Context The population of Suffolk is expected to increase by >7% by 2021/22. In Suffolk there are a high proportion of middle-aged and elderly people compared with England. Approximately 1 in 5 of the population is >65 yrs. (Public Health Suffolk, Nov 2013).

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From 2012/13, an increase of 28% is predicted for hip replacements and an increase of 48% for knee replacements in West Suffolk by 2021/22 (prior to the hip and knee pathways being established). In 2012/13, across the Suffolk Primary Care Trust area (includes current Ipswich & East and West Suffolk CCG areas) there were approximately 150,000 contacts with Physiotherapists and over 80,000 contacts in Orthopaedics at a total cost of approximately £50m. 35% of first Outpatient appointments resulted in discharge with no further investigation and 20% of patients attending a first Outpatient appointment convert to surgery within 19 weeks. The scope of the Community Physiotherapy Service for West Suffolk shall comprise:

• Core MSK services • OA Hip pathway (using established pathways) • OA Knee pathway (using established pathways) • Female Continence • Back and Neck Service (BaNS)

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

Y

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

Y

Domain 4 Ensuring people have a positive experience of care Y

Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm

Y

2.2 Local defined outcomes

• Easy access for patients, with referral possible by internet, telephone, or via any Healthcare

Professional • Patients can select their preferred location of treatment at entry to the service • All service users are seen and assessed within prescribed access targets • All service users participate in the decision about the course of their treatment and set goals

documented in a Care Plan (shared decision making) • All service users achieve their set goals • A high proportion of service users are able to self-manage without the need to return to the

service • High quality service user experience • High quality, relevant and timely information offered to all service users • High quality clinical outcomes for service users who do not go on to have surgical

intervention • High quality clinical outcomes from surgery for those users who do have surgical

intervention

The list of service outcome measures / Key Performance Indicators (KPIs) is listed in Appendix 4

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3. Scope 3.1 Aims and objectives of service The aim of the service is to provide a comprehensive, patient-centred, and easy to access community MSK service with high quality, efficient service in line with national guidance and local requirements. The service objectives are:

• To give patients a choice of where they receive their treatment • To provide improved access to care closer to home • To reduce waiting times to access the service and deliver treatment to enable patients to

reach their individual treatment goals sooner. The service should aim to improve Patient Quality of Life, including the ability to return to work and improved pain management.

• To ensure that all patients receive treatment according to their clinical need with routine patients treated in chronological order, thereby minimising the time that the patient spends on the waiting list and thus improving the quality of their patient experience

• To deliver clinically effective treatments that reduce the demand on secondary care (acute) services and reduces the need for more costly interventions

• To provide community services that have a strong emphasis on patient education and self-management, thereby promoting active, healthy lifestyles and reducing recurrence of injury or illness

• Provide feedback, advice and guidance via phone, email and face to face for referring clinicians as to how conditions can be managed within primary care where appropriate, or provide advice and guidance on requests to encourage and promote up-skilling in primary care

• Assess clinically and refer onward patients who are not appropriate for treatment within the service

• Assess clinically and refer backward patients who may be managed by their own GP practice in primary care

• Provide a holistic, one-stop (where appropriate) service for patients • To operate well planned and clearly articulated care pathways, covering the defined

presentations and conditions and delivering safe, evidence-based care • To ensure each patient sees a person with relevant skills, using the right equipment, in a

suitable location • To deliver the shortest pathway possible, compatible with best patient outcomes • To deliver an integrated service which works closely with other service providers across the

local healthcare system maximising efficiencies and delivering high quality care • To emphasise the benefits of Physiotherapy to ensure that referrers access the service for

all appropriate patients • To improve the patient experience by reducing Did Not Attend (DNA) and cancellations

3.2 Service description / care pathway The Community MSK service shall offer patients a choice of sites and access to specialist treatment within the local community. The service shall cover the range of MSK problems common to primary care. These include, for example, but are not limited to:- Upper Limb: Hand & Wrist, Elbow, Shoulder Lower Limb: Foot and Ankle, Knee, Osteoarthritis (OA), Hip, Rheumatology

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Back and Neck: Assessment and treatment of back and neck pain for patients who do not require specialist intervention. Onward referral to Back and Neck Service (also included in this contract) as appropriate. Women’s Health: The service shall provide a specialist integrated approach to the management of patients with stress incontinence, urgency, cyctocele, utero-vaginal prolapse, rectocele, postnatal and postoperative conditions. This approach shall be centred on a specialist physiotherapy and continence service which includes advice on diet, weight-loss, alcohol and smoking cessation. Other specialist services Additional specialist services included in scope where there is likely to be benefit from MSK physiotherapy include:

• Patients with learning disabilities requiring MSK physiotherapy • Vertigo • Headaches

The service shall provide triage, assessment and management for all patients registered with a West Suffolk Clinical Commissioning Group (WSCCG) GP practice and for all those the CCG is responsible for under the ‘Who Pays’ guidance. The service shall be delivered by qualified and registered Physiotherapy practitioners. Any diagnostics (e.g. x-rays, scans) must be performed by practitioners who possess the relevant and up to date training and accreditation. Referrals shall be triaged in a community setting, with patients being seen and managed within the Community Physiotherapy service, or referred on to other appropriate services, as necessary. Following the triage of a referral, the following options shall be available:

• Patient discharge with advice for self-care management • Assessment and treatment by a qualified practitioner • Referral onto an appropriate MSK pathway (e.g. OA Hip) where applicable (see below) • Referral back to the GP with advice re management in general practice • Onward referral to secondary care, where appropriate • Onward referral to the community pain service, where appropriate • Onward referral to another community service, where appropriate

The service shall complete a thorough history and undertake physical assessment of patients with suspected MSK disorders. Following assessment, the Provider shall document a Patient Care Plan. The Provider shall ensure that any appropriate investigations are subsequently arranged and reviewed. In discussion and agreement with the patient, referrals shall be transferred to the most suitable provider of treatment; taking into account patient choice, general health and psychosocial factors, and ensure that the 18 week referral to treatment (RTT) pathway timescales are met. A diagrammatic representation of the pathway is included in Appendix 1. Signposting to various pathways and services OA Hip and Knee Patients diagnosed with OA Hip shall be assessed and treated as directed by the OA Hip pathway specified in Appendix 5. Patients diagnosed with OA Knee shall be assessed and treated as directed by the OA Knee pathway specified in Appendix 6.

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Back and Neck Service Patients diagnosed with back pain shall be assessed and treated as directed by the Back and Neck Service (BaNS) pathway specified in Appendix 7. Female Continence Female patients requiring specialist advice and treatment for incontinence shall be assessed and treated as directed by the Female Continence pathway specified in Appendix 7. Referrals to other services The Service shall act to identify patient needs beyond typical Physiotherapy needs. This aims to ensure that the patient is signposted to the most appropriate service as quickly as possible to support their needs. The Provider is required to be aware of all the relevant local services provided and support the patient to make contact with them.

Falls - all patients who self-refer and are > 65 yrs. shall be asked if their injury is as a result of a fall, and if they have fallen in the last 6 months. Where there is a confirmed falls risk, the Provider shall perform a Stage One and Stage Two falls assessment as described in the West Suffolk (WS) Integrated Falls & Fragility Fracture (IFFF) Assessment and Management Pathway:

http://www.westsuffolkccg.nhs.uk/wp-content/uploads/2014/04/WS-Integrated-FFF-Assessment-and-Management-Pathway-Part-1-V13-Dec13ppt.pdf

The Provider should take action as directed by the pathway, to provide treatment and support for the patient if this is within the remit of the Service, or refer the patient to the appropriate local healthcare team. For further information on falls, see the West Suffolk CCG website:

http://www.westsuffolkccg.nhs.uk/clinical-area/falls-and-fragility-fracture/.

Patients who meet the Pain Service criteria of persistent pain for more than three months should be referred to the Community Pain Service (this service is currently being procured by the CCG). 3.3 Population covered The service shall be available to patients registered with the GP practices that are members of the West Suffolk Clinical Commissioning Group (Appendix 2) and for those for whom the CCG is responsible under the ‘Who Pays’ guidance. 3.4 Any acceptance and exclusion criteria and thresholds Referral Criteria The service shall be available to people aged 16 years or over, with a particular focus on older people, with a suspected or recognised MSK condition requiring further investigation, assessment and/or diagnosis, prior to treatment options.

The service shall accept referrals from; GPs, other Healthcare Professionals and patient self-referrals (open access)..

The service shall only accept referrals for patients registered with a WSCCG GP Practice, or for whom the CCG is responsible, and who do not satisfy any of the exclusion criteria listed below.

Referral Process For GP or other Healthcare Professional referrals, the referrer shall either complete a service referral form, or ask the patient to refer themself via a self-referral system. GPs shall be provided with a card containing the service contact details. This shall be given to patients that agree to self-refer following a GP practice consultation. Patients with MSK conditions shall access the self-referring system via a web based portal or by

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telephone. The Provider shall use SystmOne as the Clinical IT System.

The Provider is required to be N3 compliant with the capability to upload to National systems including, but not limited to Secondary Uses Services (SUS) and Unify. The national reporting requirements are detailed at the link; http://www.ic.nhs.uk/datasets.

The Provider shall also be required to provide a monthly Contract Performance and Quality Assurance report. The Contract Performance report shall include, but not be limited to; KPI reporting, activity reporting including discharge summaries, Friends & Family reporting.

The Contract Quality Assurance report shall include, but not be limited to Personal care planning, Patient experience, Complaints, Compliments, Harm free care, Serious Incidents and Safeguarding

The final reporting requirements shall be agreed between the Commissioner and Provider.

Discharge Process The Provider shall be responsible for ensuring that the patient’s GP is sent a discharge summary letter within 3 Working Days of discharge from the service, outlining the diagnosis, investigations, treatment plan, recommendations and patient advice following each patient consultation. The patient shall also receive a copy of their discharge letter, if, when asked, they indicate that they would like a copy. For one year following discharge from the service, patients can self-refer back to the service, for the same condition as the original referral. Exclusion Criteria The service is not available to;

• Patients registered with a GP practice outside WSCCG (Appendix 2) • Those requiring emergency treatment • Those with suspected serious pathology, or red flag symptoms (see below) • Those with conditions unlikely to benefit from conservative Physiotherapy management • Those who have previously not responded to Physiotherapy treatment for the same presenting

condition unless there are good indications that further treatment shall provide improved outcomes

• Patients who require diagnostic investigations which should be completed prior to referral • Patients under 16 years of age • Patients with a neurological condition requiring specialist neurological physiotherapy • Patients unable to give informed consent (following the principles laid out in 4.1K and 4.1L

below) • Patients who require Physiotherapy treatment post operatively where treatment is available via a

separate, defined and commissioned pathway

‘Red flag’ symptom is the term given to the identification of dangerous or potentially dangerous findings in the history or examination.

Red flag symptoms include;

Reference: http://www.thephysiotherapysite.co.uk/physiotherapy/physiotherapists/articles/40/assessing-red-flags

• Bodyweight loss, if the reason for the weight loss is not clear • Losing one’s appetite

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• Feeling unwell - anyone who complains of persistently feeling unwell, especially with loss of appetite and weight loss, should be regarded with suspicion

• Pain on rest and at night - if the pain is particularly bad lying down, or at night, it should be recorded as a suspicious finding

• Early morning stiffness - lasting for an hour or more - could be due to a rheumatoid condition • Previous medical history of a tumour - a recurrence could be the presenting cause of the

patient's problems • Bladder and bowel function - not previously present, or an inability to pass water (retention), is

important and should be immediately reported • Perineal loss of sensitivity • Spasticity and hyper-reflexia - any significant increase in tone, reflexes or clonus could indicate a

central nervous system problem • Generalised loss of muscle power • Thoracic pain - most MSK spinal pains occur in the lumbar, sacral or cervical areas and are

benign. Thoracic pain is associated with a higher risk of serious conditions such as tumours, and this should be taken into account

3.5 Interdependence with other Providers The service shall be integrated with other Providers in primary, community and secondary care settings. Where a referral is outside the scope of this service, the Provider shall work closely with other Providers, to ensure the appropriate care is provided to patients. The Provider shall ensure that onward referral and signposting is carried out in a timely fashion and does not contribute to a delay in treatment, where treatment is required. In addition, the service shall be accessible to all Health Care Professionals and the Provider shall be required to facilitate and develop robust two-way referral mechanisms so that patients can move easily between different parts of the system when required. Key interdependencies include:

• West Suffolk CCG GP practices • Secondary care (including specialist assessment services) • Community services • Local CCG Education & Training resources • Patient and Public Engagement groups • Community Pain Pathways

The Provider shall develop links with relevant organisations in the voluntary sector. The Provider shall be required to be involved in any local networks that are of relevance to this service, such as the local networks relating to the specialty area. 3.6 Equipment If the Provider assesses that the patient needs simple l equipment as part of their episode of care and treatment plan, , such as a walking stick, simple ready-made splints , strapping or taping, then these shall be provided to the patient, at no charge by the Provider. The cost of providing this equipment shall be included in the attendance fee.

The Provider shall refer to specialist services, such as Biomechanics and Orthotics, for consideration for the provision of more specialist or bespoke equipment and appliances.

The Provider shall refer to Community Services for any aids or appliances for home use if clinical needs dictate, e.g. rails on stairs, equipment for bathing and toileting.

3.7 Communication: marketing and highlighting services All members of the local health system should be informed about the use of the pathways for referral and signposting. This may include, but shall not be limited to:-

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- visiting GP Practices to promote pathways and gain feedback on issues - creating service information leaflets - for patients and GPs - organising, and/or, attending events to promote best use of the pathways

4. Applicable Service Standards 4.1 Applicable national standards (e.g. NICE) The Provider shall deliver services in accordance with best practice in health care and shall comply in all respects with the standards and recommendations contained in:-

a. Registration with the Health and Care Professions Council and compliance with their guidance including Standards of proficiency – Physiotherapists http://www.hpc-uk.org/assets/documents/10000DBCStandards_of_Proficiency_Physiotherapists.pdf

b. The Chartered Society of Physiotherapists (CSP) including Core Standards of physiotherapy practice http://www.csp.org.uk/publications/core-standards-physiotherapy-practice; Scope of Physiotherapy Practice http://www.csp.org.uk/sites/files/csp/secure/PD001%20Scope%20of%20Practice%202008.pdf and Rules of Professional Conduct http://www.csp.org.uk/professional-union/professionalism/csp-expectations-members/professional-rules

c. The local pathway that shall be made available through Map of Medicine, (where available) d. All recognised clinical service standards such as evidence based clinical guidelines from the

CSP and other similar bodies e. Care Quality Commission registration standards (where applicable i.e. the provider is within

scope of registration) f. National Institute for Health and Clinical Excellence guidance,

NICE Guidance, Osteoarthritis: The Care and Management of Osteoarthritis in Adults. February, 2014. NICE Guidance, Rheumatoid Arthritis: The Management of Rheumatoid Arthritis in Adults, February, 2009. NICE Pathway – Musculoskeletal Conditions (http://pathways.nice.org.uk/pathways/musculoskeletal-conditions)

g. National Service Frameworks and national strategies National Services Frameworks (Long Term Conditions, 2005, Older People, 2001) Musculoskeletal Service Framework - A joint responsibility: Doing it Differently, Department of Health (2006).

h. National Patient Safety alerts and guidance i. Clinical negligence for Trusts/ NHS Litigation Authority Scheme requirements including

adequate insurance cover. j. Changing Our Lives – Quality of Health Principles – http://www.hqip.org.uk/assets/ppe/case-

studeis-and-templates/qualityofhealthpriniciples.pdf k. Suffolk County Council – Suffolk’s Charter for People with Learning Disabilities and their

family carers http://www.suffolk.gov.uk/assets/suffolk.gov.uk/Care%20and%20Support/Adult/Learning%20disabilities/big%20messages%20charter.pdf

l. Any other quality standards agreed in writing between the provider and the Commissioner.

4.2 Applicable standards set out in Guidance and/or issued by a competent body (e.g. Royal Colleges)

The most recent evidence base best practice standards to be applied to the delivery of this service, including prescribing. The Provider shall ensure that all healthcare professionals who are involved in performing or assisting in any procedure are:

• competent in resuscitation; • able to demonstrate that their skills are regularly updated; • able to demonstrate a continuing sustained level of activity; • able to conduct regular audits;

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• participate in appraisal of MSK activity; • participate in supportive educational activities.

The Provider is required to maintain evidence of continuing professional development in relation to this service. This may be required to be produced as evidence for re-accreditation. Clinical updates/training could include, though is not limited to; supervised practice, liaison/clinical audit sessions or attendance at appropriate postgraduate meetings/lectures/events. The Provider shall complete a minimum of two audits per year. Examples of topics to focus on include:

• Clinical outcomes • Rate of infection • Complications of cases • Completeness of care episode • Patient satisfaction (to be carried out at least quarterly) • Instrument/ surgical equipment is up to date

The Provider must be N3 Compliant (or working toward this) with capability to upload to National systems including SUS & Unify. 4.3 Applicable local standards The Provider shall adhere to the WSCCG Clinical Prioritisation Policies and agree to abide by any future amendments of policy which may affect the provision of the service. The Provider shall work in line with local infection control guidelines. 4.4 Service response times For the purposes of clarity, the required response times for all services commissioned within this Service Specification are included in Appendix 3 – summary of all Standards the Provider shall be required to meet in full. The Provider shall be required to meet all of the standards included in this Specification. After receipt of the referral, patients should be contacted (by telephone, email or letter) within 5 Working Days with an offer of:

- Self-management information, - An appointment meeting the criteria below, and, or - Referral/signpost to another service

Following agreement with the patient of their appointment date and time, a confirmation of appointment should be sent to the patient by their preferred method of communication (email, letter, telephone or text.) on the day that the appointment is confirmed. The Provider should recognise that patients may have pre-existing schedules and commitments. Accordingly, when making the appointment booking, all efforts should be made to accommodate the patient’s schedule. Due consideration should be given to the requests of the patient in terms of location, frequency and time of day, within the practical constraints of the contracted service. Initial assessment - Patients triaged as “Urgent” shall be seen and assessed within 10 Working Days. Initial assessment - Patients triaged as “Routine” shall be seen and assessed within 20 Working Days. DNAs (Did Not Attends)

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Patients who do not attend their agreed and confirmed first appointment should be discharged back to the care of their referring source, and the referrer and patient informed of this action. The onus in this discharge has to be for the patient to re-initiate contact with the service, not for the GP to have to follow up with the patient. Patients who do not attend their agreed and confirmed follow-up appointment should be given one further opportunity to attend. Patients who then DNA their second and subsequent agreed and confirmed follow-up appointment should be discharged back to the care of their referring source, and the referrer and patient informed of this action. The onus in this discharge has to be for the patient to re-initiate contact with the service, not for the GP to have to follow up with the patient. When a patient contacts the service following a DNA and requests a further appointment, the decision whether to grant this request should be made by the Provider Health Care Professional, following a review of the patient’s DNA circumstances and clinical need. In most cases it is expected that this request for an appointment is granted. The Provider should use all reasonable means at its disposal to, wherever possible, reduce the rate of DNAs by making further and more frequent contact with the patient, to remind them of their appointment arrangements. Patient initiated cancellations Patients should be allowed to cancel their previously confirmed appointment and request a rebooking once, and a second appointment date and time agreed with the patient. If the patient then cancels their second confirmed appointment, the patient should be discharged back to the care of their referring source, and the referrer and patient informed of this action. Similarly, if a patient requests termination of their treatment cycle, the patient should be discharged back to the care of their referring source, and the referrer and patient informed of this action. Service initiated cancellations Where patient appointments have to be cancelled, the Provider shall offer alternative dates, within 5 Operational Days, to the patient without significantly lengthening their treatment pathway time. Wherever possible, patients who have been cancelled once should not be cancelled again, except as the result of an urgent clinical re-prioritisation, and there being no other options. Unfit patients Patients deemed unfit for their treatment should be discharged back to the care of their referring source, and the referrer and patient informed of this action. Transfers When a patient moves from a WSCCG GP practice to another area, they may wish to transfer their treatment to another provider closer to their new home. In this instance, the patient should be referred back to their referring source, and the referrer and patient informed of this action. The referring source should be responsible for referring the patient to their new appropriate primary care provider. Patient information The Provider shall ensure that, as part of the admission process, patients are well informed about their condition and about what to expect within the Service. They should be given information about any procedures and recovery process, including information on aftercare, how to access other relevant services out-of-hours and also reassurance that the clinician caring for them is suitably qualified/experienced. The information should also be available on the Provider’s website which shall include detailed patient information about all common MSK conditions and related procedures. Where possible, this should be diagrammatic and visual, and include examples of real patient stories (case studies). The

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Provider shall also ensure that the patient is given an opportunity to ask questions and receive reassurance as necessary. The service shall be available, as necessary in order to meet with the requirements of the Service Specification, with particular focus on required waiting times, so as not to compromise the 18 week Referral To Treatment pathway. As a minimum, the Provider shall ensure the Service is provided, Monday to Friday during core hours (08.30 to 17.00 hrs.) with sufficient clinics to meet waiting time criteria. Opening times should be flexed to meet demand and shall include some evenings. The definition of a Working Day is Monday to Friday 08.30 – 17.00 hrs. The Provider shall provide access to appropriate translation services for patients speaking little, or no English. If required, longer appointments should be offered for these patients, or those with disabilities. Patients (particularly those who require ongoing care within the Service) should be supplied with contact details for a named clinician who can respond to queries and concerns, and, where necessary, give clinical telephone advice. Equal opportunities:

The Provider must demonstrate how they meet equal opportunity requirements in the following areas:

• They must be committed to equal opportunities and must not discriminate in performance of the service towards service users or members of staff in any way

• The provision of same-sex therapists and/or chaperones at the patient’s request • The provision of premises, facilities and treatment rooms that are compliant with disability

legislation • Access to foreign language interpreter or sign language interpreters, if necessary • The provision of written patient information in a variety of languages appropriate to the patient

population in the CCG. The maximum timescale for the implementation of multi lingual literature will be 6 months from the service commencement date, to be contained within the contract Service Development and Improvement Plan.

5. Applicable quality requirements and CQUIN goals 5.1 Applicable quality requirements - see Appendix 3 for Local Quality Requirements (Schedule 4C)

5.2 Applicable CQUIN goals (See Schedule 4 Part E) 6. Location of Provider Premises The Service shall be delivered from multiple locations across the WS CCG area. As a minimum, the Provider shall offer clinics in premises located no more than 30 minutes travelling time from the patient’s registered GP practice. The Provider shall ensure that:

• the sites have sufficient patient parking to facilitate access to the site • access to the buildings and clinics is compliant with the Disability Discrimination Act (2004) • the service is delivered in an area that is fit for purpose; there is access to an area suitable

for the provision of group work/class work/gym work • there is access to toilets /changing facilities for all patients • there is access to a private room for more confidential assessment or treatment • Appropriate clinical support is in place within the site of delivery to provide emergency care if

required.

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7. Individual Service User Placement N/A

Patients seeks advice

from their GP

Red Flag

Refer to secondary care

GP informs patient of choices for community Physiotherapy

provider.

Priority Urgent or Routine

URGENT

Seen within 10 Operational Days of referrall

ROUTINE Seen within 20

Operational Days of referral

GP informs patient on referral routes • Self-referral (web/phone) • Choose & Book (or similar

future system)

Y

Primary Care

Community Provider records referral and

acknowledges.

Triage referral

Sign post to other service or GP

Other issue

Discharge with advice and SOS access (1 year)

No treatment

• Patient appointment booked • Register on system • Appointment confirmation

and initial advice sent to patient

Appendix 1: Care Pathway

N

Eligible

Referral from secondary care

Self-Referral

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* Hip and Knee pathways: Stage 1 = Conservative Treatment; Stage 2 = Pre-operative

OA HIP*

COMMUNITY MSK

Patient attends first assessment, for assessment & initial treatment Appointment includes: EQ5D questionnaire(insert for other pathways when confirmed), Health Plan, Information

leaflet, next appointment (if required)

Physiotherapist requests patient; medical history, drug history, X-Rays / MRI, if appropriate (would all of these be just for some patients as opposed to all?)

Stage 1

Stage 2

Secondary care

referral (Choice offered)

Discharge from service (Outcome scores e.g. EQ5D, Oxford Hip/Knee)

FEMALE CONTINENCE

OA KNEE*

Stage 1

Stage 2

Secondary care

referral (Choice offered)

Sign post to other service

Back to GP for further

care

To secondary care (Choice

offered)

Discharge home, self-manage + SOS

BACK AND NECK SERVICE

(BaNS)

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Appendix 2: Population covered

List of West Suffolk CCG GP practices

D83003 WICKHAMBROOK D83012 CLEMENTS CHRISTMAS MALTINGS, HAVERHILL D83013 GUILDHALL & BARROW, BURY ST EDMUNDS D83014 LONG MELFORD D83018 MARKET CROSS, MILDENHALL D83021 CHRISTMAS MALTINGS, HAVERHILL D83027 ORCHARD HOUSE, NEWMARKET D83029 ROOKERY, NEWMARKET D83033 BOTESDALE D83045 LAKENHEATH D83055 WOOLPIT D83060 HARDWICKE HOUSE, SUDBURY D83064 GLEMSFORD D83067 OAKFIELD, NEWMARKET D83070 AVICENNA, HOPTON D83075 SIAM SURGERY, SUDBURY D83076 CLARE GUILDHALL D83078 WHITE HOUSE, MILDENHALL D83618 STOURVIEW, HAVERHILL D83005 ANGEL HILL, BURY ST EDMUNDS D83038 MOUNT FARM, BURY ST EDMUNDS D83040 VICTORIA, BURY ST EDMUNDS D83610 SWAN SURGERY, BURY ST EDMUNDS D83062 FOREST SURGERY, BRANDON Y00774 BRANDON

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Appendix 3 –Summary of all Standards the Provider shall be required to meet in full.

All All patients shall be offered first appointment within 5 Working Days after receipt of referral (or less if dictated by rules below) Discharge summary letter sent to GP practice within 3 Working Days of discharge from service.

Core MSK Urgent patients seen and assessed within 10 Working Days after receipt of referral Routine patients seen and assessed within 20 Working Days after receipt of referral

OA Hip service

All patients seen and assessed within 10 Working Days after receipt of referral Telephone follow-up at 20 and 40 Working Days after completion of treatment

OA Knee service

Patients with acute knee injury, anterior knee pain or early OA to be triaged within 1 Working Day of receipt of referral Patients with acute knee injury – seen and assessed within 3 Working Days of triage All other patients seen and assessed within 20 Working Days after receipt of referral Telephone follow-up at 20 and 60 working days after completion of treatment

BaNS All patients seen and assessed within 25 Working Days after receipt of referral If requiring Multi-Disciplinary Team (MDT) opinion – considered by MDT within 25 Working Days following initial assessment Outcome of MDT meeting notified to GP practice within 3 Working Days

Female Continence service

All patients sent advice leaflet within 2 Working Days after receipt of referral All patients seen and assessed within 10 Working Days after receipt of referral

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Appendix 4 – Key Performance Indicators (KPI)

KPI

Method of Measurement

1. Total number of patient referrals contacted within 5 Working Days, a threshold of ≥98%

Service Quality Performance Report (SQPR)

2. Total number of patients with acute knee injury only, initial face to face assessments and treatments completed within 4 Working Days from initial referral, a threshold of ≥98%

SQPR

3. Total number of initial URGENT face to face assessments and treatments completed within 10 Working Days, a threshold of ≥98%

(CORE KPI)

SQPR

4. Total number of initial ROUTINE face to face assessments and treatments completed within 20 Working Days, a threshold of ≥98% (CORE KPI)

SQPR

5. Back and Neck Service - Total number of patients seen and assessed within 25 Working Days of initial referral, a threshold of ≥98%

SQPR

6. Back and Neck Service – If requiring MDT opinion, the case note review is completed within 25 Working Days following initial assessment, a threshold of ≥98%

SQPR

7. Agreed and validated improvement in symptoms scores after treatment. At least 70% of all patients completing treatment achieve their goals as evidenced by the EuroQol 5 data measure (EQ-5D) of a threshold of ≥90%

(CORE KPI)

The sample shall include all patients completing their course of treatment.

SQPR

8. OA Hip pathway Agreed and validated improvement in symptoms scores after treatment - Oxford Hip Score

SQPR

(need further advice on this wording Mary P reviewing)

9. OA Knee pathway Agreed and validated improvement in symptoms scores after treatment - Oxford Knee Score

SQPR

(need further advice on this wording and if there is a specific outcome measure for BaNS and female continence, or if EQ5D is appropriate?? Quality to advise??

10. NHS Friends and Family test – Net Promoter Score of ≥80

The sample size shall be a minimum of 30% of patients discharged from the service

SQPR

Comment [IS1]: The EQ-5D health questionnaire provides a simple descriptive profile and a single index value for health status. This measure is suitable for all services within this Specification. http://www.euroqol.org for more info.

Comment [IS2]: Need to review this

Comment [JR3]: We need to define how many achieve goals and what % complete treatment

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11. The number of patient discharge summary letters sent to the patients registered GP practice within 3 Working Days of discharge from the service, a threshold of ≥95% (CORE KPI)

SQPR

12. 100% of patients have a documented Care Plan following the initial assessment

SQPR

13. Number of patients who feel they have been involved in the development of their Care Plan - 70%

SQPR

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Appendix 5: OA Hip Pathway

Key Service Outcomes • Improved self-care through patient education and information as well as refresher referrer

education • Reduced waiting times for physiotherapy • Improved quality and consistency of referrals into secondary care, to include documented

preliminary investigations • Reduced waiting times for outpatient services and surgery • Improved outcomes post-surgery, as measured by patient-recorded outcome measures

(PROMS) as well as reduced recovery times and readmissions • Increased patient satisfaction • Flat or reduced overall expenditure on the OA hip pathway against historical levels Service Description

The West Suffolk Hip Assessment Service (SHAS) will provide an integrated approach to the management of patients with OA hip disease. This approach will be centred on a physiotherapy-led, multi-disciplinary service (to include advice on diet and weight-loss, smoking cessation, pain management and occupational therapy) to support patients prior to referral to hospital for a hip replacement procedure as well as input to a standardised approach to prioritising patients’ treatments – the Oxford Hip Score

Service Model

The service shall be organised and run by Physiotherapists, who will also deliver a significant proportion of the interventions as well as coordinating input from other experts such as Dieticians, Pharmacists and Occupational Therapists. The other experts shall be from those services already commissioned by the CCG.

The service will consist of two main programmes: one for patients with established OA hip disease (i.e. who can no longer be managed in primary care alone with simple analgesia, but who may not require an immediate hip replacement procedure); and one for patients with severe OA hip disease (i.e. who will need hip surgery in the near future).

Patients with established OA hip disease will receive:

• Initial face to face assessment (one-to-one), within 10 Working Days of referral • 4 x 1.5 hour group sessions (up to 7 patients per group)

– Rolling programme – General fitness and flexibility – Specific exercises to strengthen and mobilise – Weight loss and dietary advice – Pain control and management – Smoking cessation – Discussion with ‘expert’ patient / video from an expert patient – Assessment for equipment available (e.g. perching stools)

• Individual assessment after session 4 • Telephone follow-up to review the patient’s progress at 20 and 40 Working Days after

completion of treatment (session 4) • In addition, there shall be provision for a small number of patients to receive additional

one-to-one interventions if any of the post-group assessments indicate that this would be appropriate

• 6 month follow up review at patient’s request The focus of this programme is on support to manage the condition.

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Patients with advanced/severe OA hip disease will receive:

• Initial face to face assessment (one-to-one), within 10 Working Days of referral • 3 x individual interventions (with provision for some home visits for patients with very

severe OA who would not be able to attend a clinic) The group sessions shall be provided at a minimum of four locations across the West Suffolk CCG area, and shall be provided in either core hours, or in the early evening. The focus of this programme is on optimal preparation for surgery and improving post-surgical outcomes.

At the initial assessment, the Provider shall record the patient’s Oxford Hip score to determine their overall priority for surgery.

The Oxford Hip score shall also be recorded at the final individual session after session four.

Patients with severe OA hip shall be assessed by the service in the same way as all other patients and their referrals will then be accelerated through to secondary care for a T&O Outpatient appointment and consultant assessment for surgery. The Provider shall ensure that all referrals to secondary care include a completed T18a form. The T18a form is included in Appendix 6.

Patients with ‘red flag’ symptoms shall be referred directly into secondary care and may also be assessed by the service in the same way as all other patients. These patient referrals will not be delayed for the sole purpose of completing any assessment although the referral shall accompanied by a completed T18a form.

Care pathways

West QP8 hip pathway FINALv2 5.p

Referral Criteria

Hip pain that can no longer be managed with simple analgesia and basic physiotherapy X-ray evidence of established OA of the hip

Discharge Process

Patients with established OA hip disease

Patients with established OA hip disease shall complete a programme of 4 group sessions followed by a follow-up telephone call one and two months post the completed group sessions. . If it is determined that the patient is managing the condition successfully, the patient shall be discharged from the service and advised to contact their GP if their condition deteriorates significantly. Alternatively, the patient can contact the service directly for re-assessment.

Patients with advanced OA hip disease

Patients with advanced OA hip disease will complete a programme of 3 individual sessions, and, depending on their clinical condition* and the shared decision between the patient and physiotherapist, may at the same time be referred to Orthopaedic outpatients for consultant assessment and probably listing for surgery. Choice must be given if referring to secondary care.

* There is some evidence that indicates that people with an Oxford Hip or Knee score of below 20 should be referred for joint replacement.

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Appendix 6: OA Knee Pathway

Key Service Outcomes • Improved self-care through patient education and information, as well as refresher referrer

education • Reduced waiting times for physiotherapy • Improved quality and consistency of referrals into secondary care, to include documented

preliminary investigations • Reduced waiting times for outpatient services and surgery • Improved outcomes post-surgery, as measured by patient-recorded outcome measures

(PROMS) as well as reduced recovery times and readmissions • Increased patient satisfaction • Flat or reduced overall expenditure on the OA knee pathway against 2010/11 levels Service Description

The service shall provide an integrated approach to the management of patients with knee problems and especially for OA Knee disease/degenerative meniscus as detailed in the West Suffolk Knee Pathway. The West Suffolk Knee Pathway is included under the Care Pathways heading later in this Service Specification

This approach shall be centered on a physiotherapy-led, multi-disciplinary service (to include advice on diet and weight-loss, smoking cessation, pain management and occupational therapy) to support patients prior to referral to acute hospital for a knee replacement procedure as well as input to a standardised approach to prioritising patients’ treatments using the Oxford Knee score .

Service model

The service shall be organised and run by Physiotherapists, who shall be expected to deliver a significant proportion of the interventions as well as co-ordinating input from other experts such as Dieticians, Pharmacists and Occupational Therapists. The service shall consist of three main programmes:

• Patients with acute knee injury, anterior knee pain or early OA; • Patients with established OA knee disease (i.e. who can no longer be managed in

primary care alone with simple analgesia but who may not require an immediate knee replacement procedure);

• Patients with severe OA knee disease (i.e. who will need knee surgery in the near future). Patients with acute knee injury, anterior knee pain, or early OA ONLY shall;

- be triaged by a Senior Physiotherapist within 1 Working Day of receipt of referral, and; - be seen and assessed within 3 Working Days of triage,

Patients with established OA knee disease shall receive:

• An initial face to face assessment and treatment , within 20 Working Days of referral • 5 x 1.5 hour group sessions (up to 8 patients per group)

– General fitness and flexibility – Specific exercises to strengthen and mobilise – Weight loss and dietary advice – Pain control and management – Smoking cessation – Discussion with ‘expert’ patient – Assessment for equipment available (e.g. perching stools)

The group sessions shall be provided at a minimum of four locations across the West Suffolk CCG area, and shall be provided in either core hours, or in the early evening.

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• Individual assessment after group session 5 • Telephone review 20 and 60 Working Days after completion of treatment (after session 5) • In addition, the Provider shall ensure that there is provision for a small number of patients

to receive additional one-to-one interventions if any of the post-group assessments indicate that this would be appropriate

• A 6 month follow up review at patient’s request

The focus of this programme is on support to manage the condition Patients with advanced OA knee disease will receive:

• An initial face to face assessment within 20 Working Day of initial referral • A referral to secondary care on completion of the first appointment for a T&O Outpatient

appointment and consultant assessment for surgery • 3 x individual interventions (with provision for some home visits for patients with severe

OA who would not be able to attend a clinic) • The focus of this programme is on preparation for surgery and improving post-surgical

outcomes At the initial assessment, the Provider shall record the patient’s Oxford Knee score to determine their overall priority for surgery.

The Oxford Hip score shall also be recorded at the final individual session after session four. Patients with severe OA knee, or with ‘red flag’ symptoms shall be assessed by the service in the same way as all other patients and their referrals will then be accelerated through to secondary care for a T&O Outpatient appointment and consultant assessment for surgery. These patients’ referrals will not be delayed for the sole purpose of completing any assessment. The Provider shall ensure that all referrals to secondary care include a completed T18a form in Appendix 7. If referred to secondary care then Choice of Provider must be offered.

Care pathways

West QP8 knee pathway V3 1 FINAL.

Referral Criteria and sources

Knee pain that can no longer be managed with simple analgesia and basic physiotherapy X-ray evidence of established OA of the knee

Onward referral to Trauma and Orthopaedics consultants Early specialist assessment and treatment is advised with the following symptoms, condition, or preferences:

• OA Knee Patient choice Severe OA determined by x-ray and Oxford Knee score No measurable improvement after the group sessions have been completed

• Acute knee Knee locking, giving way, or a potential bone injury

Discharge process Patients with established OA knee disease Patients with established OA knee shall complete the programme of 5 group sessions and shall l receive a review telephone call from the Provider one and three months after completion of the group sessions.

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Patients managing their condition successfully shall be discharged from the service and advised to contact their GP if their condition deteriorates or to self-refer to the Community MSK physiotherapy service. Patient with advanced OA knee disease Patients with advanced OA knee disease will complete the programme of 3 individual sessions and, depending on their clinical condition* and the shared decision between the patient and physiotherapist, may at the same time be referred to Orthopaedics Outpatients on first assessment for consultant assessment and probably listing for surgery. The referral will have attached a completed T18a form. * There is some evidence that indicates that people with an Oxford Hip or Knee score of below 20 should be referred for joint replacement.

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Appendix 7 - T18a and b form

The policy and checklists for hip and knee surgery are updated from time to time and are contained at:

http://www.westsuffolkccg.nhs.uk/clinical-thresholds/

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Appendix 8: Back and Neck Service (BaNS) Service Specification

1. Purpose

Aims

• To provide fast access to clinically appropriate local treatment for patients in West Suffolk CCG, with persistent back and neck pain.

Evidence Base

• Clinical Standards Advisory Group 1994 • The prevalence of Back Pain in Great Britain 1998 DH • MSK Framework 2006 DH • Allied Health Professional (AHP) Framework 2008 DH • Spinal Task Force 2010 DH • NICE guidelines CG88 low back pain

General Overview

The Back and Neck Service (BANs) is a specialised service provided to people with persistent back and neck pain who are registered with a West Suffolk CCG GP practice. It commenced in the east of Suffolk in 2003, and, combined with learning from the Forest Heath Consortium Low Back Pain Pathway, was established in the west of the county in August 2010.

GPs initially encourage patients to self-manage using tried and tested protocols and refer them to the Musculoskeletal (MSK) physiotherapy service when appropriate. Those patients who prove to have more complex problems are referred on to Extended Scope Physiotherapists (ESPs).

The service includes a weekly ESP-led multi-disciplinary case note review of complex patients with consultant/specialist pain and spinal surgeon input, leading to a decision on future treatment. The ESPs have a role in developing the skills of the MSK physiotherapists as well as assessing those more complex patients.

Objectives

To ensure that patients with persistent back and neck pain;

• Assessed and treated sooner, and recover faster

• Where clinically appropriate, have prompt access to consultant-led care by encouraging GPs to work to improve patient self-management, investing in musculoskeletal physiotherapy in the community, introducing extended scope physiotherapy and building an ESP-led multi-disciplinary team

Expected Outcomes • Improved self-management • Timely referral to the most appropriate clinician • Timely assessment and treatment • Improved recovery times • Faster access to secondary care, when appropriate • Reduction in referral into secondary care, • Transfer of knowledge and expertise from ESPs to MSK physiotherapists

2. Scope Service Description

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The Back and Neck Service (BANs) is a multi-disciplinary spinal triage system based in primary care and provides a link between secondary and primary or community care. It has been designed to effectively assess, investigate where appropriate, and refer patients to secondary care when necessary.

Accessibility/acceptability

The service shall be available to people aged 16 years or over, registered with a West Suffolk CCG GP practice with back and, or, neck problems

Whole System Relationships

The Back and Neck Service ESPs work within primary care and are the link between primary and secondary care, easing access to secondary care for those for whom secondary care will be essential, and ensuring speedy resolution of care needs for those who have no need of secondary care, by triaging referrals, ordering necessary investigations, diagnosing conditions, or by discussion with the ESP led multi-disciplinary team.

Interdependencies

The West Suffolk CCG BANs ESPs work with primary or community care MSK physiotherapists in the west of the county, the Pain Consultant/Associate Specialist from West Suffolk Hospital.

The MSK physiotherapists shall be employed by the Community MSK service Provider.

The Provider shall work with the radiology department at West Suffolk Hospital for the provision of scans, reports and, where necessary, further discussion. There may be a link with other secondary care consultants, e.g. rheumatology, to facilitate appropriate patient care.

3. Service Delivery Service model

The service model seeks to encourage patients to self-manage wherever possible. However it is recognised that when this is not possible the patient needs fast access to the most appropriate level of intervention. This is achieved using the Community MSK physiotherapy service in the first instance to assess and treat the patient. These physiotherapists shall have direct access to the ESPs and refer the patients when clinically appropriate.

The ESPs assess the patients’ needs and may order further investigations. They will discuss with the patient the need for these investigations and the possibility of referral to secondary care following the MDT meeting. For patients who remain in primary care these investigations are requested on behalf of the GP, but for those who continue to secondary care it is considered that they are ordered on behalf of secondary care.

The ESP led MDT case note review allows those patients who require secondary care to be referred directly and ensures that those who have no need of secondary care are given the appropriate level of support to lead to resolution of their needs. Following the MDT, the ESPs will follow up with the patient to discuss the next steps, either by telephone or at a direct face to face clinical appointment.

When a patient has been reviewed at the MDT, the Provider shall send a letter to the patient’s GP practice within 3 Working Days, copied to the patient and the referrer, informing them of the outcome of the MDT meeting.

Referral criteria & sources • Back or neck pain which is not being helped by the core Community MSK physiotherapy service • Radicular pain which is not resolving within 6 weeks from onset of symptoms Spinal stenosis, which is not being helped by the core Community MSK physiotherapy and is at least 6-8 weeks from onset of symptoms

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Response time & detail and prioritisation 98% of patients shall receive an initial face to face assessment and treatment within 25 Working Days of referral to the BaNS service. Prioritisation shall be based on clinical need and at the request of the MSK service physiotherapist.

• Urgent - severe radicular pain for greater than 3 weeks duration - night pain waking patient

• Routine - persistent neck or back pain not being helped by physiotherapy At the initial face to face assessment the ESP shall determine the need for further investigation and whether or not the patient’s case notes should be reviewed at the MDT. The case notes shall be discussed at the first MDT following receipt of results of investigation. This will be within 25 Working Days following initial assessment. Discharge criteria and planning

Discharge planning is discussed and agreed with the patient. Discharge from the BaNs is: -

• Referral to Pain or Spinal secondary care • Back to the Community MSK physiotherapy service • Back to GP care

Patients are referred back to the care of the GP if either, their spinal problems are resolved and they are able to self- manage, or if they require a referral to another specialism. Patients are referred back to the Community MSK physiotherapy service if they do not require referral to either Pain or Spinal secondary care but their spinal problems are not yet resolved and they need further advice in self-management techniques. Patients are referred to Pain or Spinal secondary care if it is agreed at the MDT that this is clinically appropriate. Discharge letters shall be sent to the GP, referrer and the patient within 3 Working Days.

Prevention, self-care and patient and carer information

• The Provider shall ensure that self-management leaflets are available. • The Provider shall ensure that information booklets about the routine secondary care procedures are

available.

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Care Pathway

Patient seeks advice from their GP

Community MSK Physiotherapy service

Spinal ESP

Spinal MDT

( l h )

Inflammatory disorders: referral to secondary care

Rheumatology

*Red Flags: referral to secondary care

Patient self refers direct to MSK physiotherapist

Secondary care

Discharged * Red Flags

• >20 years old • Significant trauma • Bladder/bowel disturbance • Saddle anaesthesia • Severe night pain • Generally unwell/weight loss • Thoracic pain • Bilateral sciatica • Previous history of cancer,

steroids or HIV

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Appendix 9 – Female Continence Physiotherapy Service

Community female continence service A physiotherapy led service for the management of patients with women’s health / urinary continence conditions.

Key Service Outcomes • To provide specialist physiotherapy assessment and early intervention of various women’s health

conditions • To provide the patient with the upmost dignity and confidentiality • To provide a fast, flexible and integrated community based out-patient service from multiple sites

across the locality • Reduced waiting times for women’s health physiotherapy • Reduced referrals for acute hospital outpatient services and surgery • Improved outcomes post-surgery, as measured by patient-recorded outcome measures (PROMS),

reduced recovery times and readmissions • Increased patient satisfaction • Flat or reduced overall expenditure on the women’s health pathway against historical levels • Shared decision making – when patients are referred to the service, clear information is given.

Patients are provided with sufficient information and the opportunity to discuss their options in order to make a fully informed choice.

1. Purpose 1.1 Aims & objectives The principal aims & objectives of the pathway are: • To improve patient access to female continence advice and treatment services. • To provide advice and treatment to women who may not previously have sought continence advice. • To provide specialist advice and treatment for; urinary incontinence, specialist pelvic floor, low key

bladder dysfunction and postnatal problems. • To provide optimal pre-operative preparation e.g. physiotherapy that enables patients to manage

their condition better, and/or to prepare for surgery, as well as reducing post-operative recovery times and improving post-operative outcomes.

• To make the most appropriate use of secondary care hospital resources by ensuring that those patients referred into secondary care are appropriate and optimally prepared for surgery to achieve the best possible outcomes.

• To improve the patient pathway by developing localised protocols and referral documentation as well as facilitating joined-up and holistic working between primary care, community services and secondary care.

• To enable patients with women’s health problems to manage their condition more effectively to improve their quality of life

• To reduce waiting times for women’s health physiotherapy • To provide a cost-effective and integrated service • To accept referrals from GPs, secondary care hospital Consultants and the Community continence

service. To onward refer to the Community continence service and secondary care continence specialities.

1.2 National / local context and evidence base In the current context of minimal growth in budget allocations, there is a need to provide a timely, efficient, high quality specialist Community female continence service in West Suffolk CCG. A UK study interviewed 502 women, of whom 206 responded positively to the stress urinary

29

incontinence (SUI) question, giving a prevalence rate for SUI of 41% (Haslam 2004). Due to the highly sensitive nature of this health care issue woman may take up to 10 years before seeking help. They may be too embarrassed to seek advice and may not wish to bother until their problem becomes chronic and surgery may be required. Urinary incontinence is a common problem among adult women. Conservative management is recommended as the first-line treatment. Physiotherapy, particularly pelvic floor muscle exercise, is the mainstay of such conservative management. Pelvic floor muscle exercise is particularly beneficial in the treatment of urinary stress incontinence. Studies have shown up to 70% improvement in symptoms of stress incontinence following appropriately performed pelvic floor exercise. This improvement is evident across all age groups. There is evidence that women perform better with exercise regimes supervised by specialist physiotherapists, as opposed to unsupervised, or leaflet-based care. There is evidence for the widespread recommendation that pelvic floor muscle exercise helps women with all types of urinary incontinence (Price et al 2010). The guidelines3 recommend that conservative therapy should be an option for all incontinent women. Conservative therapy such as pelvic floor muscle exercises, biofeedback, cones and electrical stimulation is relatively inexpensive, readily available and has few complications (RCP, 1995). Other studies have suggested that supervised specialist physiotherapy by members of the Association of Chartered Physiotherapist’s in Women’s Health (ACPWH) or ACPWH’s ‘sister’ organisations internationally, working as part of a multidisciplinary team are more effective than community standalone physiotherapy services in reducing the workload and operating time of surgeons. NICE guidelines2 recommend 3 months of supervised pelvic floor exercises before referral to secondary care.

2. Service Scope

2.1 Service description The service shall provide a specialist, integrated approach for the management of patients for the full list of conditions included in Section 3.5.2 This approach shall be centred on a specialist physiotherapy service which works closely with the Community continence service, primary and secondary care. The Provider shall be required to offer advice on diet and weight-loss, alcohol and smoking cessation. 2.2 Exclusion criteria

The following are excluded from the service;

• Patients under the age of 16 years • Patients with;

- a neurological condition requiring specialist neurological physiotherapy - microscopic haematuria - faecal incontinence - unless post-natal and, or, associated with urinary incontinence - patients unable to give informed consent

Patients with the following ‘red flags’; • Pelvic mass • Neurological emergencies – inability to pass urine, saddle anaesthesia etc. 2.3 Geographic coverage /boundaries As per the criteria set out in the Community MSK Service Specification, section 3.3

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2.4 Whole system relationships - effect on other services General Practice / Primary Care / Secondary Care: • GPs and other healthcare professionals shall refer patients with female continence problems to this

service to provide then with additional support and information about the best treatment options • The secondary care Urology team shall refer patients to this service for whom outcomes will be

improved by the various interventions.

The Community continence service • Physiotherapists in the Community female continence service shall be required to liaise with referrers

from the Community continence service in order to contribute to the development of the patients final Care Plan. Physiotherapists in the Community female continence service shall be required to work closely with the Community continence team to ensure that patients are provided with e appropriate, integrated care to support the best possible outcome.

2.5 Interdependencies with other services The service shall ensure adequate communication is maintained with GP practices, the secondary care Urology team at West Suffolk Hospital Foundation Trust (WSFT), and the Community Continence service. The service shall be able to make direct referrals to these services. 2.6 Clinical governance The service shall be professionally and legally responsible and accountable for all aspects of their own work, including the management of patients in their care, in accordance with the standards and codes of ethics and rules of professional conduct of the Chartered Society of Physiotherapy, the Chartered Society of Physiotherapists in Women’s Health and the Health Professions Council Standards. The service shall be responsible for ensuring that there are robust clinical supervision outcomes and arrangements in place, and that all staff employed by the service receives appropriate, clinical professional development of any staff employed in the service.

3. Service Delivery 3.1 Service model The service shall be organised and run by physiotherapists, who shall undertake the assessments, interventions and be required to co-ordinate input from other experts such as the Community Continence service and the secondary care Urology service. All patients accessing the service shall receive a standard advice leaflet (to be co-produced by the Provider, Community Continence service and Commissioner) which shall be sent via email or post to the patient within the timescale defined in the Access Policy The Provider shall be responsible for providing bladder diaries to all referrers and shall make the diaries available electronically for patients to download. Bladder diaries shall be given to all patients for completion at the point of referral, ahead of the initial appointment with the Provider. The Provider shall complete a full vaginal assessment at the first appointment, as part of the overall clinical assessment, where clinically indicated with the patients consent.

The service shall provide bladder drills and shall complete frequency volume charts, where clinically necessary At the initial appointment, after discussion between the patient and physiotherapist a Care Plan shall be agreed and documented. Patients shall be offered a minimum of three appointments. The first appointment shall be no less than 1

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hour duration. The length of follow up appointments shall be determined based on clinical need. The interval between appointments is expected to be one month, though will flex according to patient need. The Provider shall ensure that the following activities are completed, as a minimum at each appointment;

• pelvic floor exercises and education • bladder control, diet, weight loss, alcohol and smoking cessation advice

The Provider shall be required to undertake a full re-assessment at the third appointment.

The objective of the treatment programme is to support the patient to manage their condition. Patients identified by the Provider with suspected ‘red flag’ conditions shall be referred directly to secondary care at a hospital of their choice – the details of the referral shall be communicated to the GP practice, via copy of referral letter. 3.2 Location of service delivery As per the locations set out in Section 6 of the Community MSK Service Specification 3.3 Day / hours of operation As per the details set out in Section 4.3 of the Community MSK Service Specification 3.4 Referral processes • Referrers shall either complete a referral form, or give the patient a card with the service web and

telephone access details. • Patients shall be offered an initial appointment for assessment / treatment within 10 Working Days

from the date of referral. 3.5.1 The service shall accept referrals for the following conditions; • Prolapse – mild or moderate. Can be written as ‘prolapse, cystocele, rectocele, urethrocele, uterine

prolapse, vault prolapse, cervix prolapse, anterior wall prolapse, posterior wall prolapse’ • Prolapse, large pre-surgery input • Post prolapse surgery input • Post anterior / posterior repair input • Stress incontinence • Urgency incontinence • Mixed incontinence • Pelvic floor weakness • Lack of sensation postnatally • Postnatally, e.g. following tear etc. • Vaginismus / pelvic floor spasm • Can see patients with rectal incontinence if part of a mixed picture i.e. with urinary incontinence, not

purely for rectal incontinence as not a colorectal service currently. 3.5.2 The Provider shall onward refer patients to secondary care ( Gynaecology / Urogynaecology or Urology) under the following circumstances; • Incontinence persists after 12-16 weeks of input • The patient has a large prolapse • At patient request 3.6 Discharge processes Patients with resolving Women’s health problems Patients with resolving health problems shall be encouraged to complete the programme of three monthly assessment and treatment sessions. If they are managing their condition successfully, they will

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then be discharged from the service and advised to contact their GP if their condition deteriorates significantly. Alternatively, the patient can self-refer to the service direct for re-assessment. The GP practice shall receive a discharge letter as per the requirements included in the Standards in Appendix 3. Patient with un-resolving Women’s health problems Patients with un-resolving women’s health problems shall complete the programme of three monthly assessment treatment sessions. All patients experiencing simultaneous urge shall also be referred on to the Community continence service. The Provider shall provide, if required, electrical stimulation. Patients who have not responded to stimulation treatment shall be referred on to Gynaecology / Urology Outpatients at a hospital of their choice for consultant assessment.

4. References 1. Lamb SE, Pepper J, Lall R, et al (2009) Group treatments for sensitive health care problems: a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence. BMC Women’s Health.

2. National Institute for Health and Clinical Excellence (2006) Urinary incontinence: the management of urinary incontinence in women. CG40. London: National Institute for Health and Clinical Excellence. URL: http://guidance.nice.org.uk/CG40) 3. Royal College of Physicians (1995) Incontinence: causes, management and provision of services. A report by The Royal College of Physicians. 1 – 5 4. Price N, Dawood R, Jacobs S. (2010) Pelvic Floor Exercise for Urinary Incontinence A Systematic Literature Review. Department of Obstetrics and Gynaecology, John Radcliffe Hospital, Oxford 5. Haslam J (2004) The Prevalence of Stress Urinary Incontinence in Women. Nursing Times;

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Community Women's Incontinence Service Pathway

Physiotherapist receives referral

General advice sheet sent to patient

Physiotherapy - Patient is graded and

recieves education including bladder

control, diet, weight loss, alcohol

cessation, surgrey and pelvic floor

exercises

Grade 0-3 poor cerebral awareness 1:1 physiotherpy to

include electrical stimulation

Patient reviewed

Signs of improvement , if appropraite to re-

enter flow chart at grade 3+- 1:1

sessions for pelvic floor exercises

No improvement: patient referred

direct to consultant.

Grade 3+ - 1:1 sessions for pelvic

floor exercises Patient reviewed

Slight improvement, Action to be taken as deemed appropraite

by the physiotherapist

60% resolved; discharged and

encouraged to self manage and continue

with exercises

No improvement: patient referred

direct to consultant.

Referral to Continence Service

Grade 0-3 good cerebral awareness 1:1

physiotherpy to include biofeedback

Patient reviewed

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Female Urinary Incontinence Pathway

Causes can include UTI, weak pelvic floor muscles, prolapse, atrophy, detrusor muscle dysfunction, obstruction, incompetent sphincter, urethral diverticulum, fistula, congenital lesion, cognitive impairment

Refer if:

Haematuria / Bladder / urethral / pelvic pain / Associated faecal incontinence / Difficulty voiding / Suspected urogenital fistula / Previous pelvic cancer therapy / Palpable bladder / pelvic mass / Previous surgery for incontinence /

Neurological disease (CVA/MS/SCI) / <12mths post-partum and abnormal examination

Stress incontinence: Involuntary leakage on effort or exertion, or on sneezing or coughing

Urge Incontinence: Involuntary leakage accompanied by or immediately preceded by urgency

History to establish predominant symptoms (stress or urge)

Appropriate examination & dipstick urine

If symptomatic prolapse found at or below vaginal introitus refer to Gynaecology

Refer to physiotherapist for supervised pelvic floor muscle training for 3

months

If symptoms improved,

consider withdrawal of pharmacological

treatment after period of bladder training

Lifestyle advice

Lose weight, reduce intake of fluids to 1.5 litres daily, stop caffeine & reduce alcohol intake

Refer to either Urology or Gynaecology

with a report from continence advisor / physiotherapist

Symptoms persist

Refer to continence advisor for bladder training for 6 weeks

Consider pharmacological treatment at the same time*

Consider vaginal oestrogen if

If mixed,

then treat predominant

symptom

Mainly stress Mainly OAB +/- Urge

No improvement despite bladder training and no

response to 1st- or 2nd-line pharmacological treatments

PHARMACOLOGICAL TREATMENT – see below

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*Pharmacological Treatment

Prescribe the lowest recommended dose when initiating treatment If 1st-line treatment is ineffective or not tolerated, offer 2nd-line treatment When offering antimuscarinic drugs consider:

• coexisting conditions (e.g. poor bladder emptying) • concurrent drug treatments with antimuscarinic effects • risk of adverse effects (particularly confusion in elderly patients who are more susceptible to adverse effects; monitor

cognitive function) Full benefits may not be seen until treatment has been taken for 4 weeks 3rd line treatment with mirabegron is an option if 1st- and 2nd-line antimuscarinic treatments are contraindicated, ineffective or

not tolerated, in line with NICE TAG 290. Mirabegron must hospital-initiated in the WSCCG.

Choice Drug Class Drug Form Notes

1st-line

Antimuscarinic Tolterodine Tablets, immediate-release

Oxybutynin Tablets, immediate-release Avoid in frail older women

2nd-line

Antimuscarinic Trospium Capsules, modified-release

Trospium Tablets, immediate-release

Darifenacin Tablets, modified-release

Fesoterodine Tablets, modified-release

Tolterodine Capsules, modified-release

Solifenacin Tablets, immediate-release

Oxybutynin Tablets, modified-release

Oxybutynin Patches

Only for patients unable to tolerate oral medication

3rd-line

Selective beta 3-adrenoceptor agonist

Mirabegron

Tablets, modified-release ‘Green’ drug in WSCCG:

must be hospital initiated, then continued by the GP

Drug treatments are listed in order of cost-effective choice based on the maximum dose

Review 4-6 weeks after the start of any new drug treatment, and then after 6 months to assess if still required

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General Requirements

1 Information Technology

1.1 The Provider must be involved in the local delivery of national, regional and local programmes for IM&T projects, including (but not limited to) promotions and distribution of materials.

1.2 In line with nationally prescribed guidance the Co-ordinating Commissioner requires commitment from the Provider to ensure informatics planning is aligned to NHS Funded Services. This in turn recognises the critical importance of identifying and supporting information flows across the health community. Particular attention and delivery of the following is required:

• addressing the national expectation described in NHS England’s Achieving An Integrated Digital Care Record

• development and agreement of a roadmap for progress against the Clinical Digital Maturity Index as set out by NHS England

1.3 The Provider shall agree to support and be involved in the delivery of the Commissioners Informatics Plan once it is published.

1.4 The Provider will ensure that they produce an IM&T business continuity/recovery plan that meets the requirements described in NHS England’s Business Continuity Management Framework and follows the principles and processes of the ITIL v3 Library (2. Service Delivery – Availability Management and 5. The Business Perspective.) as well as relevant NHS Information Governance & IM&T requirements. This plan should demonstrate that the Provider has robust systems in place to manage IM&T risks including the provision of system resilience, business continuity and disaster recovery.

1.5 The Provider is required to have systems in place that allow full electronic data sharing against standards defined in the NHS Interoperability Tool Kit (ITK) as set out in a Report from the NHS Future Forum. The key requirement is interoperability-IT systems talking to each other-not a ‘national programme for IT’. The Provider must have drawn up an ‘information strategy’ that clearly sets out, when and how this will support the Co-ordinating Commissioners and NHS England’s IT Strategies. Guidance is expected, which the Provider must follow, including any deadlines brought forward.

2 Information Governance 2.1 For the avoidance of doubt, the Provider is a Data Controller (which has the meaning as set

out in the Data Protection Act) in respect of any data that they process in their own right

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2.2 The Co-ordinating Commissioner expects the Provider to comply with the following: • Continued on-going compliance with the reporting requirements of UNIFY 2 and

SUS, which includes compliance with the required format, schedules for delivery of data and definitions as set out in the Information Centre Guidance and All Information Standards Notices (ISNs), where applicable to the service being provided.

• Where the Provider is part of a multi provider pathway then the Provider shall be expected to actively participate in the development of integrated information flows that are consistent, complete and timely and compliant with all mandatory data items.

• Active participation in the provision of daily information to support the system wide

urgent care dashboard.

• The Provider shall endeavour to submit all corrections to SUS so that SUS becomes the definitive source of data together with any amendments being submitted as Net change (as opposed to bulk change) within the nationally mandated PbR timescales.

• The Provider shall be expected to work with the Co-ordinating Commissioner and

the DSCRO on various areas including but not limited to: Data quality, data standardisation, data flows, data access, invoice validation and implementation of agreed processes between the Co-ordinating Commissioner and the DSCRO.

3 Equality and Diversity 3.1 The Provider shall support the Co-ordinating Commissioner with the delivery of their

Equality and Diversity Plan and NHS Equality Delivery System (EDS), as per ED2 outcomes and grading’s. The Plan is available in Schedule 2G

3.2 The Provider needs to comply with the public sector Equality Duty and Equality Act 2010. As a public sector body NHS Trusts are required to:

• Publish information to show compliance with the Equality Duty, at least annually; and

• Set and publish equality objectives, at least every four years.

3.3 In the exercise of its functions, the Provider must have due regard to the need to:

• Eliminate unlawful discrimination, harassment and victimisation and any other conduct prohibited by the Equality Act;

• Advance equality of opportunity between people who share a protected characteristic and people who do not and;

• Foster good relations between people who share a protected characteristic and people who do not;

• have considered and documented the impact on the equality of their decisions e.g. through Equality Analysis or Impact Assessment.

4 Health Services for the Veterans and their families

4.1 The Provider is expected to comply with relevant guidance from the Department of Health

5 Workforce

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5.1 The Provider is required to have a workforce plan that reflects their Commissioning Strategy and financial plans. The plan should be made available to the Co-ordinating Commissioner upon request

5.2 The Provider is required to demonstrate compliance to European Working Time Directive (WTD) regulations which support safe working arrangements. The Provider shall supply a copy of WTD Doctors in Training Monitoring return, if requested

5.3 In cases where staff rotas have been awarded WTD Derogation, the Provider needs to demonstrate that action plans are in place and delivered to ensure European Working Time Directive compliance. The Provider shall supply an Action Plan following on from WTD Doctors Training Monitoring return, if requested

5.4 The Provider is required to work with the West Suffolk and Ipswich and East Suffolk Clinical Commissioning Group, Norfolk and Suffolk Workforce Partnership Group and NHS England to ensure that their established future workforce requirements relate to the Commissioners intentions

5.5 The Provider is required to have agreed a target for reduction of sickness absence levels. The Provider is expected to work towards a target of 3.5 % in line with the recommendation of its Trust Board. The Provider ensures their staff have access to required health interventions to support a reduction in absence. The Coordinating Commissioner may from time to time request information detailing what interventions have been implemented

5.6 The Provider is expected to review current workforce operations in order to improve Service User experience and service quality and to deliver services more efficiently and more cost effectively

5.7 Education Commissioning is integral to appropriate workforce planning therefore all service providers are responsible for providing placements for students commissioned by the Norfolk and Suffolk Workforce Partnership Group (as per the LDA) following agreement of student numbers

5.8 The Provider is required to demonstrate that they have key components to underpin medical revalidation that help doctors remain up to date and fit to practice throughout their career. The Provider shall evidence that medical staff are remaining up to date by supplying a sample of records if requested.

5.9 The Provider is expected to work towards increasing workforce productivity compared with the 2012/13 baseline and aligning Provider Workforce Plans with the Commissioner's QIPP Plans

5.10 The Provider should work with the Norfolk and Suffolk Workforce Partnership Group to identify the Education and Training implications of planned service changes and support the Co-ordinating Commissioner with the pre-and post-registration education investment plans to address the needs identified, by the end of March 2015.

5.11 The Provider must work with the Norfolk and Suffolk Workforce Partnership Group to ensure that action is taken to ensure continuing European Working Time Directive (EWTD) compliance

5.12 The Provider will aim to ensure that those members of staff who have disclosed long term conditions undertake a self-assessment against the Personal Health Plan Workforce Guide (where such assessment would not be considered to be in breach of the Equality Act or other statute or regulation).

5.13 The Provider is expected to monitor and work towards improved organisational performance in the annual NHS Staff Survey using 2012/13 results as a baseline. Evidence of planned improvements will be expected to be provided

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5.14 The Provider is required to ensure arrangements are in place to ensure that any person they appoint to a post has the knowledge of English necessary to perform their duties in line with existing requirements under the Performers List Regulations 2004 and Health Circular 1999/137.

5.15 The Provider shall implement the Releasing Time to Care Programme across all Service User facing services. Providers who have not fully implemented the Programme will be expected to agree an action plan for implementation and provide Co-ordinating Commissioners with progress reports. Time lines to be determined.

5.16 The Provider is required to have a systematic approach to improving dignity in care for Service Users, give staff appropriate training and incorporate learning from the experience of Service Users and carers into their work, using where applicable, the safeguarding adult self-assessment (SAAF) and children’s markers of good practice

5.17 The Provider should ensure that their Occupational Health Service have made the necessary application for accreditation to the Faculty of Occupational Medicine Standards implementing recommendations set out in NICE public health guidance to improve staff health and wellbeing

6 Re-tendering and Handover

6.1 Where the Co-ordinating Commissioner has notified the Provider that any Commissioner intends to tender or re-tender any Services, the information to be provided by the Provider under General Condition 5.14 shall include, as applicable, accurate information relating to the employees who would be transferred under the same terms of employment under those Regulations, including in particular (but not limited to):

a. the number of employees who would be transferred, but with no obligation on the Provider to specify their names;

b. in respect of each of those employees, their dates of birth, sex, salary, length of service, hours of work and rates, and any other factors affecting contractual and redundancy entitlement, any specific terms applicable to those employees individually and any outstanding claims arising from their employment;

c. the general terms and conditions applicable to those employees, including Whitley Council provisions, probationary periods, retirement age, periods of notice, current pay agreements and structures, special pay allowances, working hours, entitlement to annual leave, sick leave, maternity and special leave, injury benefit, redundancy rights, terms of mobility, any loan or leasing agreements, and any other relevant collective agreements, facility time arrangements and additional employment benefits.

6.2 Where the Services are to be retendered or offered to another external supplier other than the Provider, the Commissioner shall take all necessary precautions to ensure that the information referred to in General Condition 5.14 is given only to suppliers who have qualified to offer for the future provision of Services. The Commissioner shall require that such suppliers shall treat that information in confidence, that they shall not communicate it except to such persons within their organisation and to such extent as may be necessary for the purpose of preparing a response to an invitation to offer issued by the Commissioner and that they shall not use it for any other purpose.

6.3 The Provider shall co-operate fully with the Commissioner during the handover arising from the completion or earlier termination of the Contract. This co-operation, during the setting up operations period of the new Provider (if any), shall extend to allowing full access to, and providing copies of all documents, reports, summaries and other information necessary in order to achieve an effective transition without disruption to the routine operational requirements.

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8 Medicines Management

6.4 Within ten (10) working days of being so requested by the Commissioner, the Provider shall transfer to the Commissioner, or any person designated by the Commissioner, free of charge, all computerised filing, recordings, documentation, planning and drawings held on software and utilised in the provision of the Services. The transfer shall be made in a fully indexed and catalogued disk format to operate on a proprietary software package identical to that used by the Commissioner

7 Interpretation Services

7.1 The Provider should use face to face interpreters in addition to Language Line where appropriate and necessary to do so

8.1

Shared care must always be subject to agreement with primary care physician

• The Service User’s condition is stabilised (where possible) prior to transfer of prescribing or as part of a shared care agreement (i.e. treatment has been initiated and no further dose titration is required);

• A copy of a shared care agreement must be sent to the GP when requesting that a GP takes on the prescribing of this drug

• Prior written agreement has been reached between primary care and the provider before clinical responsibility is transferred

• The response from the GP should be logged • Monitoring is carried out as specified in the shared care document • Consultants should use the Coordinating Commissioners approved shared

care documents. The GP has the right to refuse to prescribe, however this should not be because of concerns of cost.

8.2 The Provider will adhere to the joint formulary, where clinically appropriate once

agreed. This includes chapters of the joint formulary as they are agreed by the Medicines Management Committee. Clinicians requesting GPs to start an item that is not within the joint formulary should state a valid clinical reason on the discharge summary/clinic letter why this has been chosen over a formulary option

8.3 An up to date copy of the traffic lights , joint formulary and all joint guidelines must be available for all clinicians to access on the hospital intranet The Provider will support adherence to the traffic light list and joint guidelines

8.4 Where the Provider wishes to move the responsibility for prescribing a drug to another provider i.e. secondary care to primary care or vice-versa, the Co-ordinating Commissioner must be satisfied that all costs for the drug and related activity and the Service User pathway is clear and agreed across the interface before moving funding or resources or altering the traffic light status of the drug. The Parties undertake to work collaboratively together in the consideration of each case

8.5 The Provide will report 100% of medication errors each month via the Clinical Quality Performance Report (CQPR). The CQPR report will include details of the level of harm associated with all incidence of medication errors.

8.6 The Provider will, in the normal course of events, prescribe generic drugs in preference to branded medication both in inpatient and outpatient settings unless there is a clinical safety or cost effective reason for not doing this.

8.7 The Provider will work with the Co-ordinating Commissioner regarding the appropriate use of antibiotics in the Emergency Department in line with the Primary Care Antibiotic Formulary

8.8 The Provider shall ensure all discharged inpatients (where appropriate) have access to a minimum of 14 days’ supply of drugs relevant to their condition and competency

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11 Clinical Governance 11.1 The Provider will put in place an effective clinical governance framework. This must have in

place appropriate and effective arrangements for quality assurance, continuous quality improvement and risk management.

11.2 The Provider shall nominate a person who will have responsibility for ensuring the effective

operation of the system of clinical governance. The person nominated shall be a person who performs or manages the services.

12 Patient Safety and Clinical Quality The Provider will comply with policies and procedures on:

• Infection Prevention and Control • Patient Advice and Liaison (PALS) • Complaints and compliments • Management and reporting of all incidents, including serious untoward incidences (SUI’s)

and near misses • Never Events occurrences • Risk assessment and risk management • Information Governance • Safeguarding Adults • Data protection

where clinically appropriate. For PbR excluded drugs the date of initiation must be included in the (non SUS) data received by the Co-ordinating Commissioner i.e. TPN. The Co-ordinating Commissioner will reclaim from Providers any prescription costs that result from non-adherence to this policy unless specifically agreed by exemption. Where pre-operative drugs are identified by the Provider as being necessary to facilitate treatment, the Co-ordinating Commissioner will not accept referral back or requests for primary care prescription as these are included in national tariff.

8.9 The Provider shall only copy blood test results to the GP if there is specific action required within primary care. If there is a specific action required by the GP then this should be detailed in the discharge summary. If the GP is required to take any action within 5 working days the GP must be notified by telephone or fax. The Service User must also be notified when urgent action is required by the GP.

9 Providing Safe Care

9.1 The Provider is required to comply with National Reporting & Learning System (NRLS) reporting requirements as defined by the National Patient Safety Agency (NPSA) or any successor body

9.2 The Provider shall continue to adhere to all prescribers' attention to MHRA alerts

10 Admitting Mistakes 10.1

Providers should complete central returns on mistakes, never events, incidents and complaints. The national patient experience surveys should continue to be monitored and acted upon. In addition, as part of the National Standard Contract we shall expect each local organisation to carry out more frequent local Service User surveys, including using “real time” data techniques, to publish the results – including data on complaints – and to respond appropriately where improvements need to be made.

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• Quality Assurance/ maintaining good practice • Clinical and Professional Development (CPD), supervision and training

12.2 In addition to the scope of the service and its aims, the provider will ensure the following:

• All equipment used is maintained and serviced to manufacturer’s instructions. • Quality Control and calibration of the equipment is carried out by trained staff following

manufacturer’s instruction and stated limits. • Patients and or carers receive relevant information in a format that is appropriate for the

patient’s individual needs. • Patients are satisfied with the access to the service, information given and their

management.

13 Patient Experience

The Commissioner aims to ensure that information about patient experience is used systematically to support the review of services provided to patients. The Commissioner expects that the Provider will give patients the opportunity to comment on their experience of using services on an on-going basis, through patient surveys. Patient and Public Involvement work, PALS, complaints and other activities.

14 Safeguarding Adults 14.1 Health services have a duty to safeguard all patients and provide additional measures for

patients who are less able to protect themselves from harm or abuse.

14.2 People who use services should be protected from abuse, or the risk of abuse, and their human rights respected and upheld.

14.3 To achieve this all responsible agencies and individuals must work together to prevent abuse and safeguard adults where possible, and where preventative measures fail, to deal sensitively and effectively with incidents of abuse

14.4 The Provider shall work to the Care Quality Commission guidance Essential Standards of Quality and Safety and in particular Outcome 7, Safeguarding people who use services from abuse.

14.5 In order to comply with these requirements the Provider shall ensure

• Senior management commitment to the importance of safeguarding and promoting the welfare of vulnerable adults

• A clear line of accountability within the organisation for safeguarding and promoting the welfare of vulnerable adults

• Safeguarding adults as an integral part of patient care • Safeguarding measures are understood, assured and improved • Service development that takes into account the need to safeguard and promote welfare

and is informed by the views of service users, families and carers • Effective interagency working to safeguard and promote the welfare of vulnerable adults • They comply with either Norfolk County Council or Suffolk County Council’s policies as

set out below • Suffolk Multi-Agency Safeguarding Adults Policy (2010) • Suffolk County Council’s Adult Safeguarding Policy and Operational Guidance (2010) • Arrangements for appropriate and proportional information sharing in response to

safeguarding concerns.

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15 Patient Satisfaction and Complaints

15.1 Patients must at all times be respected and treated in a kind and considerate way by staff who should at all times demonstrate a professional and patient friendly attitude. The service shall conduct a six monthly patient satisfaction survey using a questionnaire agreed with the Commissioner.

15.2 The service shall operate a complaints procedure that is in line with existing NHS Complaints standards, and shall promote this to patients, providing clear details of who to contact and how to escalate complaints to the CCG if they do not feel that their concerns have been addressed.

15.3 In addition to providing the CCG with a monthly summary of complaints received, the provider shall keep appropriate records of all complaints (verbal or written) which shall be available for audit.