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Gynaecology

Pathways

 

Barking and Dagenham, Havering and Redbridge Clinical Commissioning Groups management of heavy menstrual bleeding (HMB) and management of vaginal prolapse

Local Incentive Scheme (LIS)

Start Date:  15 May 2017 – 31 March 2018

Introduction

All practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This LIS outlines additional services to be provided to all patients registered with a GP in Barking and Dagenham, Havering and Redbridge. No part of this specification by commission omission or implication redefines essential or additional services. It is recommended that practices participating in this LIS should also be providing the contraceptive additional service.

Background

BHRUT are currently under increased pressure with regards to referral to treatment times across all specialties. Clinicians from BHRUT and BHR CCGs have identified that there are a number of procedures that are able to be carried out safely in the primary care setting. For the purpose of this Local Incentivised Scheme these are IUD insertion for the management of heavy menstrual bleeding and vaginal pessary insertion for management of vaginal prolapse. Feedback from BHRUT consultants has highlighted that there are currently a high number of patients attending BHRUT to have pessary changes as well as not having a full referral workup around management of heavy menstrual bleeding.

Plain ring pessaries (not containing any hormonal or other substance) can be an effective symptomatic treatment for uterovaginal prolapse and are more acceptable to some patients than surgery.

The fitting of an Intra Uterine Devices (IUDs) in partnership with informed patient choice can be an effective method to control heavy menstrual bleeding. Medical management in line with NICE guidelines should always be the 1st line treatment. A proper holistic assessment and individual patient circumstances and history should always be taken into account before proceeding to a procedure.

The agreed pathways are underpinned by NICE guidance (CG44 Heavy Menstrual Bleeding) and RCOG guidance on Uterine Prolapse.

Aims

The aims of this LIS are to encourage G.P practices to treat patients suffering from HMB and Vaginal Prolapse in the community setting where possible. It is also designed to:-

  • Help reduce inequality of care across BHR CCGs
  • Provide convenient primary care locations for all patients
  • Offer choice for all patients
  • Provide a cost effective alternative to secondary care supporting national and local priorities and ensuring value for money 

Eligibility

The provider must ensure that the service offered is accessible to all women and is, sensitive and respecting all areas of Race, Economics, Gender, Age, Religion, Disability and Sexual Orientation. Appropriate arrangements should be made for non-English speaking women who require interpreter services.

Exclusions

  • Exclusion criteria for Primary Care Management
  • Postmenopausal bleeding
  • Persistent postcoital bleeding
  • Persistent intermenstrual bleeding
  • PMB after Tamoxifen
  • Refer as per Fast Track 2WW guidelines
  • Active vaginal, cervical or pelvic infection including STI
  • Pregnancy
  • Pelvic Mass
  • Post-Menopausal Bleeding
  • Haematuria

Patients with a complex gynaecological history who need to be safely assessed and treated in a secondary care setting.

Service Outline

This local incentivised service is intended to fund the initial insertion & routine changing of non-complex ring pessaries and IUD by clinicians in general practice with a special skill in gynaecology. Funding is not available for pessary changes provided by district and community nurses. However, GP Practice Nurses with suitable qualifications and accreditation evidenced to the CCG can also provide this service.

Arrangements should be in place to review clients experiencing problems in a timely fashion and to provide information and treatment to manage common side effects and problems, in line with NICE guidelines and current best practice. Arrangements should be in place to ensure timely access for women requesting removal of the IUD/pessary for any reason including problems or at expiry of the device.

This local incentivised service requires practices to use disposable sterile instruments and have infection control policies in place that are compliant with national guidelines – this includes the handling of used instruments, aseptic technique and the disposal of clinical waste. An infection control audit should be completed every 12 months.

A chaperone is required throughout procedure to prepare and open equipment if required by the clinician, to assist in the event of an emergency situation and to support the client during any procedure. All chaperones should be appropriately trained and details of this training should be kept on file with regular updates as needed along with a copy of a chaperone policy.

Equipment is detailed in Appendix 1.

Qualifications and training

Practitioners involved in the delivery of this service will be appropriately trained and competent as outlined in this section. It is expected that the practitioner will have appropriate training and if possible experience of working in a gynaecology unit and demonstrate ongoing activity in this field to maintain competency.

Doctors should meet the training requirements and be awarded the letter of competence in intrauterine techniques from the Faculty of Sexual and Reproductive Healthcare (FSRH) before they are accepted as delivering this service Doctors should undertake continuing professional development and to meet activity requirements (minimum of 12 fittings per annum) in order to maintain competence.

Nurses should meet the training requirements and be awarded the letter of competence in intrauterine techniques from the Faculty of Sexual and Reproductive Healthcare (FSRH) or hold an up to date Royal College of Nursing (RCN) accreditation before they can deliver this service. Nurses should undertake continuing professional development and to meet activity requirements (minimum of 12 fittings per annum) in order to maintain competence.

Please also refer to the quality standards supplied as part of this LIS documentation.

Appraisal and audit

At appraisal clinicians are expected to demonstrate evidence of CPD and activity for IUD fitting and have log books available for review and be fully auditable.

In accordance with NICE and Good Medical Practice guidelines those interested to provide this service need to self-certify that they have the appropriate training and experience and that they will abide by the good medical practice guidelines and ensure that they keep their knowledge and skills up to date throughout the time that they are providing this LIS. Practices should submit a written application to take part in this incentivised service indicating their intention to fulfil the requirements of this LIS (form below) and their written application should include evidence of their competency to carry out these procedures and assurance that their Practice has sufficient resources for chaperoning patients.

Practices providing services under this specification will be expected to ensure that all clinicians (partners, employees, subcontractors) carrying out the fitting and removal of IUDs and pessaries are appropriately trained and qualified to do so. Practices that wish to have their Nurses accredited to provide IUCD/IUDs are required to have the following:

  • Statement of competence from an accredited trainer within the last 5 years
  • Evidence of course in Reproductive Health in the last 5 years or relevant learning in CPD plan or appraisal portfolio. Certification and accreditation must be provided to the CCGs prior to the commencement of this service.

Governance

It is recognised that a strong governance framework is needed in order to perform invasive procedures within the community setting. These treatments have been agreed with clinicians from BHRUT and BHR CCGs and follow best practice guidance from NICE and the RCOG. It is intended that a full holistic history is taken from the patient as well as any further appropriate clinical investigations to determine a full clinical picture. It is also recognised that a register of traceability is set up with regards to pessary/IUD insertion with be carried out by practices that carry out procedures. This should include batch number, date of insertion, name and designation of the staff member carrying out the procedure in order that effective clinical audit can take place when required. The practice will also agree for the CCG to audit data and confirm via practice visits should the need arise, other routines should include:-

  • Patient information should be given to all patients where possible in written form.
  • The clinician will ensure consent is obtained and informed before any procedure is carried out. This should be clearly documented in the patient’s notes as per GMC/NMC guidelines and protocols

Pricing for Service

  • Assessment and fitting of ring pessary and IUDsEach Practice contracted to provide the incentivised service will be eligible to claim the following:  G.Ps will be paid the following sum for the fitting of a IUD for management of menstrual bleeding including follow up checks.- £93 per patientClaims for services provided under this LIS must be completed and submitted to the CCG finance team on the attached claim form by the dates below on a quarterly basis.31st June 201731st Dec 2017            
    1. Claim forms to be returned to Simon Clarke simon.clarke7@nhs.net until your borough lead has been identified.
    2. 31 March 2018
    3. 31 Sept 2018
    4. G.Ps will be paid the following sum for the assessment and fitting of a ring pessary including follow up checks : - £93 per patient
    5. (Only payable for patients seen as part of this LIS).

Monitoring of patients

A suitably fitted pessary requires changing every 3 to 6 months in order to reduce the risk of ulceration and infection. As part of this LIS this will be carried out in the primary care setting.5-8 week post-insertion checks for IUDs are not a pre-requisite of, or routinely funded by this Local Incentive Scheme. The ongoing needs of patients who have had a coil fitted by the practice, including advice on the management of problems is funded by the element of Global Sum that supports contraceptive services. Routine annual checks are no longer recommended unless the patient experiences a problem with their IUD or unless the clinician feels that the patient requires a follow up. Arrangements should be in place to review clients experiencing problems in a timely fashion and to provide information and treatment to manage common side effects and problems, in line with NICE guidelines and current best practice. Practices that sign up to this LIS are asked to notify the CCG of the number of patients that they have treated per week by 5pm each Friday. This should be sent to Maryam.akbar@nhs.net. This data return is for monitoring purposes for NHSE referral to treatment targetsThe data return on page 6 must also be completed by the dates above and sent to simon.clarke7@nhs.net and for audit and cross check for payment using Health Analytics data. 

  1. The following read codes must be used to determine payment for this service:-
  • 7D1Bz for the Vaginal Prolapse insertion for Pessary
  • 9O9Z. for the IUD insertion for heavy menstrual bleeding (note that this must be used for heavy menstrual bleeding and NOT for contraception purposes.

Payments will be cross checked against Health Analytics as well as the monitoring form attached to this LIS paperwork to ensure robust collection of data. Payments will be made approximately 1 month following the data return deadline.

  1. Termination of Agreement

 Participation in this incentivised service can be terminated provided that three months’ notice is given in writing by either party.

  1. Variation of Agreement 

Variation of in this incentivised service can be varied provided that one months’ notice is given in writing by the CCG.

  1. Protecting Patient Confidentiality

The Service is required to be delivered with dignity, respect and due regard to both individuality and confidentiality. Administrative staff must be adequately trained in both patient confidentiality and gynaecological terms and policies.

The service must put in place appropriate governance and security for the IM&T Systems to safeguard patient information.

The service must ensure that the IM&T Systems and processes comply with statutory obligations for the management and operation of IM&T within the NHS, including, but not exclusively:

  • Common law duty of confidence;
  • Data Protection Act 1998;
  • Access to Health Records Act 1990;
  • Freedom of Information Act 2000;
  • Computer Misuse Act 1990; and
  • Health and Social Care Act 2012.

Acceptance of Terms

Practices wishing to participate in this scheme need to:

Complete the attached sign up agreement form and email this back to simon.clarke7@nhs.net by 12 May 2017.  Forms received after this date will not be accepted. Practices that wish to provide this service must also attach their accreditation and certification documents and return to simon.clarke7@nhs.net          

Please click on the link below to download CLAIM FORM

Downloads

pdfClaim form (0.21 MB)

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