Service Specification for the Community Pharmacy

Service Specification for the Community Pharmacy

Diabetes Enhanced Service Level 1 (2008/09)

1.Introduction

The prevalence of diabetes in the UK is currently estimated at 2.3 million people and rising: it is estimated that there will be 2.5 million by 2010. The prevalence of diabetes is higher among certain ethnic minority groups, particularly those of South Asian origin.

It is estimated that there are at least 800,000 people in the UK with undiagnosed diabetes. Increased awareness of the symptoms and signs of diabetes among both health professionals and the general public can result in the earlier identification of people with diabetes. Follow up and regular testing of individuals known to be at increased risk of developing diabetes (for example, people who have previously been found to have impaired glucose regulation, and women with a history of gestational diabetes) can lead to the earlier diagnosis of diabetes. Opportunistic screening of people with multiple risk factors for diabetes can lead to the identification of some individuals with previously undiagnosed diabetes

Structured medicines use reviews in community pharmacy provide a forum for patients to discuss issues about diabetes and their medication and this can lead to improved understanding and an improvement in their concordance to treatment

Aims and Objectives

The aims and objectives of this enhanced service are to:

Identify patients with previously undiagnosed diabetes through targeted screening of the local population;
Help patients with diabetes to improve the control of modifiable risk factors e.g. smoking, blood glucose, blood pressure, cholesterol and body weight by improved understanding of these risk factors, and providing support to modify risk factors (e.g. smoking cessation, weight management), and by addressing medication-related needs;
Improve cost-effectiveness of medicines usage. Many people with diabetes are on multiple medications: pharmacist intervention will provide a means to reduce wastage and over-use, e.g. diabetes glucose testing strips, as well as identifying under usage, e.g. blood pressure medication;
Improve understanding of diabetes and associated risk factors amongst people with diabetes, leading to increased adherence to medication regimens.

Service providers

This diabetes enhanced service has been commissioned to be provided through community pharmacies according to the following criteria:

The pharmacy must be situated in Hackney and/or be in close proximity to an area where the need for this service has been identified.
The pharmacy must have either a separate consultation room or a quiet area where conversation can be had without being overheard.
Pharmacies which are capable and able to use electronic solutions using the Pharmacy website.
Pharmacies that fulfill the above 3 criteria and have expressed an interest to deliver the service.

The pharmacy contractor has a duty to ensure that all pharmacists and staff involved in the provision of the service have relevant knowledge and are appropriately trained in the operation of the service. The contractor has a duty to ensure that standard operating procedures are developed and implemented to ensure consistency of delivery of the service.

Pharmacists providing this service must have attended the training outlined in Section 9.

Service Outline

Patient Criteria- screening

Pharmacists will both opportunistically and through referrals offer diabetes screening to people living in Hackney. who fit the “At Risk” groups listed below:

White people aged over 40 and people from black, Asian and minority ethnic groups aged over 25 years withone or more of the risk factors below

a first degree family history of diabetes and/or
overweight/obese/morbidly obese, i.e. with a BMI of 25 Kg/m2 and above, and who have a sedentary lifestyle and/or a waist measurement of ≥94cm (≥37 inches) for white and black men and ≥80cm (31.5 inches) for white, black and Asian women, and ≥90cm (≥35 inches) for Asian men
ischaemic heart disease, cerebrovascular disease, peripheral vascular disease or treated hypertension
women who have had gestational diabetes who have tested normal following delivery (screening should be undertaken within 6 weeks of delivery, then one year post- partum and then three yearly)
women with polycystic ovary syndrome who have a BMI ≥30 Kg/m2
impaired glucose tolerance or impaired fasting glycaemia
severe mental health problems
hypertriglyceridemia not due to alcohol excess or renal disease

2. People presenting with symptoms potentially related to diabetes:

thirst / polyuria
weight loss
tiredness/lethargy
recurrent/persistent cutaneous, mucosal and soft tissue infections, e.g. vaginal thrush / balanitis (penile thrush)
slow healing wounds
incontinence
neuropathy - pins and needles in the legs
visual changes such as blurred vision

Details of how to screen are laid out in Appendix 1

Appendix 2 offers step by step guidance for pharmacists.

Patient Criteria - MUR plus

Pharmacists will provide an MUR plus service to patients already diagnosed with diabetes. This will comprise additional advice and support relating to diabetes and related medication. Discussion with patients will have particular focus on modifiable risk factors covered by the “Diabetes Hand”. Details of which are available in Appendix 3

This service does not offer an alternative to a GP consultation. If a patient has a clinical problem, then they must be referred to their GP.

Who can access these services?

The success of this service relies on effective communication with General practice. CHPCT does not have any cross boundary agreements for this service; therefore the service is targeted to the following groups:

People resident in the City or Hackney and registered with a CHPCT GP.
People living outside Hackney but registered with a CHPCT GP.
Patients living in Hackney without a GP can benefit from the service but should be directed to register with a GP by contacting Find –A-Doc.

Referrers

Referrals can be accepted from anywhere, including self referral for screening. Referral for MUR plus can be accepted from GPs, Nurses and other clinical staff

Standards

Pharmacies are expected to appropriately screen at least 50 patients in the year 2008-09.
A 5% outcome of confirmed diagnosis of diabetes is expected when screening is appropriately targeted.
Pharmacies are expected to provide the MUR plus service to at least 50 patients with diabetes who are receiving services from the pharmacy.

Payments

Participation fee

Contractors who sign up to provide the service will receive a participation fee of £500. The participation fee covers attendance at the training events, record-keeping, audit

Contractors will receive the following payments:

£10 per patient screened with appropriate/approved evidence of screening

£15 per patient with a confirmed diagnosis of diabetes

£10 as top up for patients who undergo a MUR plus (NB contractors will receive the standard MUR fee for provision of the advanced service)
Reimbursement of extra boxes of lancets and test strips at Drug Tariff prices

Payments will be made monthly in arrears on submission of electronic screening and assessment forms.

8.Equipment

The PCT will provide each pharmacy with equipment to use for this service. The equipment remains the property of the PCT. These are:

BP machines.
Large Cuffs.
Blood glucose work stations.
Weight measure
Height measure.

The PCT will arrange for regular testing to ensure quality assurance of the equipment.

The use of all equipment, including disposal of clinical waste must be in accordance with Health and Safety Executive (HSE) requirements.

9.Audits

Pharmacies are expected to carry out a multidisciplinary audit of the service once a year. Details of the audits will be provided later

10.Record keeping

Since, service providers will be submitting forms via the tPCT’s Pharmacy Website ( there is no need to keep any additional records.

Training

Pharmacists providing this service must:

Attend both training evenings organised by the Prescribing Department at the PCT;
Complete the recommended CPPE package on Diabetes and provide a certificate as proof.
Agree to continually update their knowledge in the care of patients with diabetes and demonstrate competence in this area. This should preferably be recorded in a CPD portfolio.

Transfer and subcontracting

The service provider will not assign the whole or any part of the Agreement or sub-contract the supply of services without the previous consent in writing of the Purchaser, unless special conditions are included elsewhere in the Agreement.

Useful references:

NSF for Diabetes - A Guide for Community Pharmacists available on
Practice Guidance on the care of people with diabetes.
NICE guidelines
Diabetes UK

LEAD OFFICERS FOR AGREEMENT

Service Developed By:

Name: Barbara Brese

Position: Prescribing Adviser

The lead commissioning officer for this agreement is:

Name:Jonathan Mason

Position:Project Manager

Address:City and Hackney tPCT

Louis Freedman Centre

St Leonards. Nuttall Street

London

N1 5LZ

Telephone:020 7683 4454

Email:

The lead service provider officer for this agreement is:

Name:………………………………………..

Position:………………………………………..

Pharmacy:………………………………………..

Address:

Telephone:………………………………………

SIGNING OF THE AGREEMENT

This document and the attached notes comprise the Agreement concluded between City and Hackney tPCT and the pharmacy named above.

SIGNED:……….…………………………Date:…………...….….

SIGNED:……….…………………………Date:…………...….…..

Appendix 1

City & Hackney Diabetes Screening Project

Checklist – Who Should Be Screened?

The following ‘At Risk’ groups should be screened (source: Diabetes UK):

1. White people aged over 40 and people from black, Asian and minority ethnic groups aged over 25 years withone or more of the risk factors below;

a first degree family history of diabetes and/or
overweight/obese/morbidly obese with a BMI of 25 kg/m2 and above, and who have a sedentary lifestyle and/or a waist measurement of ≥94cm (≥37 inches) for white and black men and ≥80cm (31.5 inches) for white, black and Asian women, and ≥90cm (≥35 inches) for Asian men

Patients with the criteria listed below should be covered under QoF. Check first if they have been screened in the last 12 months by their GP. IF not or they don’t know, screen them.

Ischaemic heart disease, cerebrovascular disease, peripheral vascular disease or treated hypertension
women who have had gestational diabetes who have tested normal following delivery (screening should be undertaken within 6 weeks of delivery, then one year post- partum and then three yearly)
women with polycystic ovary syndrome who have a BMI ≥30
impaired glucose tolerance or impaired fasting glycaemia
severe mental health problems
hypertriglyceridemia not due to alcohol excess or renal disease

2. People presenting with symptoms potentially related to diabetes:

thirst / polyuria
weight loss
tiredness/lethargy
recurrent/persistent cutaneous, mucosal and soft tissue infections, e.g. vaginal thrush / balanitis (penile thrush)
slow healing wounds
incontinence
neuropathy - pins and needles in the legs
visual changes such as blurred vision

Assessments Conducted:

Risk and symptom questionnaire
Lifestyle
Random / fasting blood glucose
BMI and waist circumference
Blood pressure

Summary of Criteria for Referral
Symptoms Present
Symptoms of diabetes, present / Refer to GP practice
Acute development of symptoms, suspect Type 1 diabetes / Refer to GP
Symptoms absent
Risk factors, but no symptoms of diabetes
(1) Overnight fasting, finger-prick test

Consideration should be given when arranging appointments for tests, to the length of time that patients will not have eaten.
In advance of an overnight fasting test, the patient should be advised not to eat after bedtime, and to drink only water ( 8-12 hours is considered an overnight fast)

‹5.6 mmol/l (whole blood) ‹6.2 mmol/l (plasma equivalent) / Low probability of diabetes. Give advice about healthy living and reduction of risk factors
5.6 to 6.0 mmol/ l (whole blood) 6.1 to 6.9 mmol/l (plasma equivalent) / Probability of impaired fasting glycaemia/ impaired glucose tolerance Refer to GP practice
6.1 to 11.0 mmol/l (whole blood) 7.0 to 12.1 mmol/l (plasma equivalent) / Probability of diabetes
Refer to GP practice
≥ 11.1 mmol/l (whole blood) ≥ 12.2 mmol/l (plasma equivalent) / High probability of diabetes
Refer to GP practice
(2) Random, finger-prick test
11.1 mmol/l or over / Refer to GP practice with fast track appointment
5.6 mmol/l to 11.0 mmol/l / re-test on fasting sample discuss with GP practice

Random tests can be misleading and appropriate feedback to patients is essential. A random test on someone who has not eaten for more than eight hours is classed, as a ‘fasting test’

If levels are between 5.6 and 11.1mmol/l a re-test should be offered by the pharmacist using a fasting sample

A random test result of less than 5.6mmol/l indicates a low probability of diabetes.

Patient Glucose Test Record
(to be retained in the pharmacy)
I wish to have a blood glucose (sugar) test.
When was your last blood glucose test done?
- Never - don’t know - 6 months - 12months or more
Procedure for blood test:

Wash hands in warm water and dry
The finger will be pricked with an automatic device
A drop of blood will be produced
The drop will be ‘touched’ onto a strip
The result will be available in 5 seconds

Patient Name / Address
Post code
DOB / Gender /  Female  Male
Patient Identifier / Ethnicity
GP Name & Address
Date and time test undertaken / Date and approx. time of patient’s last meal prior to test
Type of test (circle as appropriate) / Fasting/ random / Serial number (blood glucose meter)
Batch number (testing strips) / Expiry date of strips
Result
Test undertaken by (name)
Role
Signature

Please tick one of the following:

I am happy for a copy of the test result to be forwarded to my GP

I have read and understood the procedure. I understand that a high blood glucose reading will need further investigation and that I do not necessarily have diabetes.

Signature ...... …..…. Date ………………………

Diabetes Screening Questionnaire

Are you at risk of diabetes?

Diabetes affects about 3% of the population in the UK and Ireland. The most common form is known as Type 2. Identifying diabetes early means that it can be treated and the risk of developing the serious complications can be greatly reduced.

Do you have any of the following common symptoms of Type 2 diabetes?

Increased thirst

Going to the loo all the time – especially at night

Extreme tiredness

Weight loss

Blurred vision

Genital itching or regular episodes of thrush

Do you have any of the following risk factors for diabetes?

If you are white:

Are you over the age of 40 and have a parent, brother / sister with diabetes?

If you come from a Black, Asian or minority ethnic group

Are you over the age of 25 and have a parent, brother or sister with diabetes?

If you have ticked yes to either of the above;

 Are you overweight?

 Are you quite inactive (no regular exercise)?

 Do you have a history of heart disease or high blood pressure?

If you are a woman:

 Did you have diabetes during a pregnancy?

 Were any of your children large at birth (over 8.8lb/4kg)?

 Do you have polycystic ovary syndrome?

If you have any of the symptoms of diabetes but none of the risk factors apply, you should consult your own GP to discuss likely causes. Do not ignore the symptoms, as they may indicate problems other than diabetes.

Even if you have no symptoms, if any of the risk factors apply, you may be at increased risk of diabetes and may wish to take a simple screening test. The test is virtually painless and available here. The test will not diagnose diabetes, but may indicate if you are at risk.

Questionnaire devised by Diabetes UK

City & Hackney PCT Community Pharmacy Diabetes Screening Recording & Referral Form to GP Practice

This patient has attended this pharmacy and requested a glucose test which has been carried out in accordance with guidelines agreed locally/nationally/by the Royal Pharmaceutical Society of Great Britain.

Patient reported that their blood glucose test & BMI were last done:

- Never - don’t know - 6 months - 12months or more

Patient Name / Patient Address
Date and time test undertaken / Type of test undertaken (circle as appropriate)
Fasting / Random
Glucose Test Result
………… mmol/l / Blood pressure
…….. mm/Hg / Waist circumference
………… inches
Height
……..m / Weight
………..kg / BMI (Kg/m2)
…… kg/m2

Reason for referral (please tick):

Possible diabetes

Possible Raised blood pressure (based on one reading)

Other (please explain):

Name & Address of Pharmacy

………………………………………………………….

…………………………………………………………

Name of Pharmacist………………………….……

Signature……………………………………………

Telephone………………Fax number ………………

Date ……………………

Outcome of referral

(To be filled by Practice and faxed back to pharmacist)

Questions / YES / NO
Was the patient subsequently diagnosed to have diabetes?

Please fax back this sheet back to update pharmacy records

Summary of WHO Diagnostic Criteria for Diabetes

- Methods and Criteria for Diagnosing Diabetes Mellitus

Adapated form Diabetes UK

1. Diabetes symptoms (i.e. polyuria, polydipsia and unexplained weight loss) plus a random venous plasma glucose concentration greater than or equal to 11.1mmol/l

a fasting plasma glucose concentration greater than or equal to 7.0mmol/l, (whole blood greater than or equal to 6.1mmol/l) or two-hour plasma glucose concentration greater than or equal to11.1mmol/l two hours after 75g anhydrous glucose in an oral glucose tolerance test (OGTT).

2. With no symptoms diagnosis should not be based on a single glucose determination but requires confirmatory plasma venous determination. At least one additional glucose test result on another day with a value in the diabetic range is essential, either fasting, from a random sample or from the two-hour post glucose load. If the fasting or random values are not diagnostic the two-hour value should be used.

Classification and terminology

Impaired Glucose Tolerance (IGT)* is a stage of impaired glucose regulation (fasting plasma glucose less than 7.0mmol/ and OGTT two-hour value greater than or equal to 7.8mmol/l but less than 11.1mmol/l).