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: I:\BGSW\SangerHouse\Commissioning\Primary Care\Pharmaceutical\Commissioning Management\Enhanced Services\Service Level Agreements\Swindon SLAs\2014-15\SLA for palliative care normal hrs.doc 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. I:\BGSW\SangerHouse\Commissioning\Primary Care\Pharmaceutical\Commissioning Management\Enhanced Services\Service Level Agreements\Swindon SLAs\2014-15\SLA for palliative care normal hrs.doc 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. I:\BGSW\SangerHouse\Commissioning\Primary Care\Pharmaceutical\Commissioning Management\Enhanced Services\Service Level Agreements\Swindon SLAs\2014-15\SLA for palliative care normal hrs.doc 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 I:\BGSW\SangerHouse\Commissioning\Primary Care\Pharmaceutical\Commissioning Management\Enhanced Services\Service Level Agreements\Swindon SLAs\2014-15\SLA for palliative care normal hrs.doc 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 I:\BGSW\SangerHouse\Commissioning\Primary Care\Pharmaceutical\Commissioning Management\Enhanced Services\Service Level Agreements\Swindon SLAs\2014-15\SLA for palliative care normal hrs.doc 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 I:\BGSW\SangerHouse\Commissioning\Primary Care\Pharmaceutical\Commissioning Management\Enhanced Services\Service Level Agreements\Swindon SLAs\2014-15\SLA for palliative care normal hrs.doc