Bath, Gloucestershire, Swindon
& Wiltshire Area Team
ENHANCED SERVICE FOR THE PROVISION OF PALLIATIVE CARE
COMMUNITY PHARMACY SERVICES IN NORMAL HOURS
Service Level Agreement (SLA) 2014-2015
1.
Introduction ................................................................................................. 1
2.
Signatures................................................................................................... 1
3.
Aims and Objectives ................................................................................... 2
4.
Service Specification................................................................................... 2
5.
Process - Pharmacy Contractors ................................................................ 2
6.
Quality Indicators Pharmacy Contractors.................................................... 2
7.
Quality Indicators PTC ................................................................................ 3
8.
Financial Details ......................................................................................... 3
9.
Monitoring Arrangements............................................................................ 3
10.
Termination of Contract .............................................................................. 3
Appendix A - Palliative Care Drugs Scheme List of Drugs stocked ......................... 4
Appendix B – Claim Form for Retainer. ................................................................... 5
Appendix C – Claim Form for Supplies for Palliative Care Provision ....................... 6
1. Introduction
This agreement set outs the framework for the dispensing of palliative care
drugs during normal hours from a community pharmacy, and has been agreed
with the Wiltshire Local Pharmaceutical Committee. The implementation,
administration, monitoring and review of this agreement is the responsibility of
NHS England Area Team, or any organisation that takes over the functions of
the Area Team.
2. Signatures:
This document constitutes the agreement between the pharmacy contractor
and the Area Team in regards to the above Service Level Agreement for the
12 months
1st April 2014 to 31st March 2015. We agree to abide by the
conditions laid out in the agreement:
Name of the Pharmacy contractor:
Signature of behalf of the
Pharmacy contractor
Name (please print)
Date
Signature of behalf of NHS
England Area Team
Name (please print)
Date:
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3. Aims and Objectives
This service aims to ensure that palliative care medicines are available during
normal working hours.
4. Service Specification
4.1.
Community Pharmacists – owners or managers agree that their
name be included in a list of names maintained by the Area Team
and provided to all pharmacies, GPs, nurses and palliative care
providers
4.2.
The pharmacists included in this scheme will be contracted to hold
a minimum stock of an agreed range of palliative care medicines as
outlined in Appendix A.
5. Process - Pharmacy Contractors
5.1.
The pharmacist will
5.1.1. Where requested, the pharmacist will provide advice to the
health care professional regarding the prescribing or dosage
of palliative care medicines that should be administered to a
patient.
5.1.2. Agree to participate in any audit of the scheme as necessary
to ensure stocks are available as stated.
5.1.3. The contractor will inform the Area Team if they have been
unable to supply the medication.
5.1.4. Submit the dispensed prescription to the PPD in the normal
way.
5.1.5. Ensure they are familiar with the local palliative care
guidelines supplied by the Area Team and will undertake any
other training as appropriate to meet their own CPD needs.
5.1.6. Use his/her professional judgement and take sole
responsibility for any supply made outside the specification
set out in this service level agreement.
6. Quality Indicators Pharmacy Contractors
6.1.
The pharmacy contractor can demonstrate that pharmacists and
staff involved in the provision of the service have undertaken CPD
relevant to this service and are aware of and operate within local
protocols. There is a CPPE distance learning course on Palliative
Care that can be undertaken to assist in fulfilling this quality
indicator.
6.2.
The pharmacy contractor reviews its Standard Operating
Procedures and the referral pathways for the service on an annual
basis.
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7. Quality Indicators Area Team
7.1.
The Area Team will
7.1.1. Ensure all pharmacies, GPs, nurses and palliative care
providers within the locality are made aware of the
pharmacies providing the Enhanced level of service.
7.1.2. Supply local palliative care guidelines.
7.1.3. Undertake to reimburse the pharmacy at the cost for the
original (set up) stock of medicines included in the agreed
Palliative Care stock list and those which have become time
expired provided normal stock rotation procedures have
been followed within the pharmacy.
8. Financial Details
8.1.
A £210 per annum retainer fee will be paid to the pharmacy
contractor participating within the scheme.
8.2.
There will be a pro rata payment (£17.50 per month) for pharmacies
that join the service part way through the financial year.
8.3.
The retainer fee will be returned to the Area Team should a
contractor withdraw from the service during the year. The amount
returned will be calculated based on a pro rata basis (£17.50 per
month).
8.4.
The Area Team will pay for the cost of the initial supply of the
medications listed in Appendix A on submission of a claim form
listing the total costs of the mediation. This stock then will be the
property of NHS England and can be reclaimed by the Area Team if
requested.
8.5.
The retainer can be claimed on submission of a Claim Form
(Appendix B).
8.6.
For any date expired stock the pharmacist will submit a Claim Form
(Appendix C) giving details of the items expired, for the attention of
the Area Team.
9. Monitoring Arrangements
9.1.
The Area Team will periodically monitor the stock levels held by
pharmacies.
9.2.
The Area Team will also monitor any claims for date expired stock.
10.
Termination of Contract
This agreement will run for a period of 12 months, however during this period,
it may be terminated by either party by giving three month written notice.
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Appendix A - Palliative Care Drugs Scheme List of Drugs stocked
Drug
Cyclizine 50mg/ml Inj
Dexamethasone 4mg/ml Inj
Diamorphine 10mg inj
Diamorphine 30mg inj
Diamorphine 100mg inj
Diazepam 5mg/ml Inj
Glycopyrronium Bromide 200mcg/ml inj
Haloperidol 5mg/ml inj
Hyoscine Butylbromide 20mg/ml inj
Hyoscine Hydrobromide 400mcg/ml inj
Levomepromazine (Methotrimeprazine)25mg/ml inj
Metoclopramide 5mg/ml inj
Midazolam 2mg/ml inj
Octreotide 50mcg/ml inj
Octreotide 100mcg/ml
Sodium chloride 0.9% inj
Phenobarbital 200mg/ml inj
Water for injection
Domperidone 30mg Suppositories
Diclofenac 100mg Suppositories
Diazepam 10mg Rectal Tubes
Prochlorperazine 25mg Suppositories
Oramorph Oral Solution 10mg/5ml
Oramorph Concentrated Oral Solution 100mg/5ml
Morphine sulphate 10mg/ml inj
Morphine sulphate 15mg/ml inj
Morphine sulphate 30mg/ml inj
Oxycodone 10mg/ml 1ml inj
Oxycodone 10mg/ml 2ml inj
Oxycodone liquid 5mg/5ml
Oxycodone concentrate 10mg/ml
Fentanyl 12 Patch
Fentanyl 25 Patch
Fentanyl 75 Patch
Fentanyl 100 Patch
Naloxone 400mcg/ml inj
Quantity
10x1ml
10x2ml
10
10
10
10x2ml
10x1ml
5x2ml
10x1ml
10x1ml
10x1ml
12x2ml
10x5ml
5x1ml
5x1ml
10x10ml
10
10x10ml
10
10
5
10
1x100ml
1x30ml
1x5
1x5
1x5
1x5
1x5
1x250ml
1x120ml
1x5
1x5
1x5
1x5
10x1ml
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Appendix B – Claim Form for Retainer
Name of Pharmacy:
Contractor Code:
This is important to ensure payments are processed efficiently
Claim for Retainer Fee
Palliative Care Provision
Retainer Fee for April 2014 to 31st March 2015
Please provide contact details for the out of hours period
Name of Pharmacist to Contact:
Telephone number:
I claim £210 retainer fee for the provision of the above enhanced service for a period of 12
months, as detailed above, and understand that confirmation of this claim may be sought or
investigated by the NHS Counter Fraud unit. I agreed to return a pro-rata amount (at £17.50
per month) should I decide to withdraw from the service before the end of the agreement.
Signed
Date
Print Name
Position
Signature:
Name:
Date:
Office use only
Payment authorised by:
Date:
Payment via NHSBSA under ADD PH ACC SERV
Please return this form to: Jon Stubbings, NHS England BGSW Area Team, Sanger House,
5220 Valiant Court, Gloucester Business Park, Brockworth, Gloucester, GL3 4FE
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Appendix C – Claim Form for Supplies for Palliative Care Provision
Name of Pharmacy:
Contractor Code:
This is important to ensure payments are processed efficiently
Claim for Reimbursement of
Expired Stock for the
Palliative Care Provision Service
Details of Expired Stock
Batch
Number
Amount
Payable
Expiry Date
£
£
£
£
TOTAL
CLAIM*
£
Please attach a copy of wholesalers invoice for replacement stock.
I claim payment of I confirm that the information given on this form is true and
complete. I understand that if I provide false or misleading information I may be liable
to prosecution or civil proceedings. I understand that the information on this form
may be provided to the Counter-Fraud and Security Management Service, a division
of the NHS Business.
Signature:
Name:
Date:
Office use only
Payment authorised by
Date
Payment via NHSBSA under ADD PH ACC SERV
Please return this form to: Jon Stubbings, NHS England BGSW Area Team, Sanger
House, 5220 Valiant Court, Gloucester Business Park, Brockworth, Gloucester,
GL3 4FE
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