Southgate House
Pans Lane
Devizes
Wiltshire
SN10 5EQ
Tel: 01380 733757
Fax: 01380 733854
e-mail:
Wiltshire Primary Care Trust
Local Enhanced Service for Supervised Administration
(Consumption Of Prescribed Medicines) 2009/2011 .

Service Level Agreement 1st April2009 – 31st March 2011

1Introduction

2Signatures

3Aims and Objectives of service

4Service Specification

5Quality Indicators

6Financial Details

7Termination of Contract

Appendix A – Wiltshire PCT 4-way Agreement

Appendix B – Pharmacy/Patient Agreement (for use where no 4-way agreement)

Appendix C – Contact Sheet

Appendix D – Service Protocol

Appendix E – Record Sheet/Claims Form

1. Introduction

This agreement set outs the framework for the supervised consumption of prescribed medicines by community pharmacists. The implementation, administration, monitoring and review of this agreement is the responsibility of Wiltshire PCT, or any organisation that takes over the functions of this PCT.

Supervised consumption

2. Signatures

This document constitutes the agreement between the practice and the PCT in regards to the above Service Level Agreement for the period 1st April 2009 to 31st March 2011.

Name of the Practice:

Signature of behalf of the Pharmacy / Name (please print) / Date

Wiltshire Primary Care Trust

Signature of behalf of the PCT / Name (please print) / Date
C J Phillips
3. Aims and objectives of service
3.1 The overall aim of this service is to ensure that, where appropriate, pharmacists* supervise the consumption of prescribed medicines to ensure that the dose has been administered to the patient. This is an enhancement to normal instalment dispensing.
3.2 Pharmacies should endeavour to provide all clients, including those using this service, a user-friendly, non-judgmental, client-centred and confidential service.
3.3 Health advice, over the counter sales and signposting should be offered as essential services under the NHS pharmacy contract.
3.4 The pharmacy will provide support and advice to the patient, including referral to primary care or specialist centres where appropriate.
3.5 Examples of medicines which may have consumption supervised include methadone and other medicines used for the management of opiate dependence, and medicines used for the management of mental health conditions or tuberculosis.
3.6 Compliance with the agreed treatment plan is promoted by:
  • dispensing in specified instalments (doses may be dispensed for the patient to take away to cover days when the pharmacy is closed),
  • ensuring each supervised dose is correctly consumed by the patient for whom it was intended.
  • The intended effect is:
  • a reduction of inadequate opiate replacement leading to a return to dependence;
  • a reduction of over usage or under usage of medicines;
  • a reduction of diversion of prescribed medicines onto the illicit drugs market;
  • a reduction of the risk of accidental exposure to the supervised medicines
  • The regular contact with health care professionals will also help service users access further advice or assistance when required.
*for Pharmacist read dispensing doctor where this service is provided in a dispensing practice.
4. Service Specification
4.1The part of the pharmacy used for provision of the service provides a sufficient level of privacy and safety.
4.2The pharmacy will liaise with the prescriber before accepting a patient for instalment prescribing with supervised consumption.
4.3All new patients being prescribed an opioid substitute should be supervised for at least the first three months (Nice TA 114). This should be stated on the prescription.
4.4The requirement for supervision should be reviewed with the prescriber after the initial three month period and periodically thereafter.
4.5Terms of agreement are set up between the pharmacist and patient to agree how the service will operate, what constitutes acceptable behaviour by the client, and what action will be taken by the pharmacist if the user does not comply with the agreement. A ‘four-way’ agreement may already be in place if the patient is under shared care arrangements between GP and specialist services, if not, the attached pharmacy agreement can be used.
4.6Doses should be supervised according to the protocol in appendix D
4.7Pharmacists will share only clinically relevant information with other health care professionals and agencies.
4.8Pharmacists should suspend instalments of methadone if more than three days have elapsed since their last instalment was due. The pharmacist should contact the prescribing doctor and/or keyworker immediately to inform them and instruct the patient to attend their service. In the case of buprenorphine the pharmacist should contact the prescribing doctor and/or keyworker immediately to inform them if the patient’s instalment is three or more days late, but may continue to dispense instalments from the date of attendance, up to seven days from the last day that an instalment was dispensed.
4.9Pharmacists should feel able to discuss any concerns regarding the patients health or well being with the prescriber/key worker.
4.10Pharmacists should not automatically inform the prescriber/key worker if patients on opiate substitute are also collecting needles for intravenous drug use as this may only lead to disengagement and the reuse of needles.
4.11The pharmacy contractor has a duty to ensure that pharmacists and staff involved in the provision of the service have relevant knowledge and are appropriately trained in the operation of the service.
4.12The pharmacy contractor has a duty to ensure that pharmacists and staff involved in the provision of the service are aware of and operate within the terms of this specification and Royal Pharmaceutical Society Guidelines.
4.13The pharmacy should maintain appropriate records to ensure effective ongoing service delivery and audit.
4.14The PCT will arrange at least one contractor meeting per year to promote service development and update the knowledge of pharmacy staff.
4.15The PCT provides a framework for the recording of relevant service information for the purposes of audit and the claiming of payment
4.16The PCO will provide health promotion material relevant to the service users and make this available to pharmacies.
5. Quality Indicators
5.1 Participating pharmacist must have:
  • Satisfactorily completed a CPPE distance learning course on drug misuse, either
  • Drug use and misuse or
  • Opiate treatment – supporting pharmacists for improved patient care.
  • A participating pharmacist must adhere to the ‘Standard for Instalment Dispensing’ in the Royal Pharmaceutical Society of Great Britain Medicine Ethics and Practice – A Guide for Pharmacists.
  • A participating pharmacist must have in place in their pharmacy suitable procedures and appropriately trained staff to ensure that the good practice detailed in this service specification operates in their absence.
  • The pharmacy has appropriate PCO provided health promotional materials available for the user group and promotes its uptake
  • The pharmacy have details of relevant referral points which pharmacy staff can use to signpost service users who require further assistance
  • The pharmacy reviews its Standard Operating Procedures and the referral pathways for the service on an annual basis.
  • The pharmacy can demonstrate that pharmacists and staff involved in the provision of the service have undertaken CPD relevant to this service.
  • The pharmacy participates in any PCT organised audit of the service provision.
  • The pharmacy co-operates with assessments of service user experience.

6. Financial Details
The Pharmacy will claim £27.00 per client per calendar month
This is independent of number of doses supervised to cover the responsibility of acting on missed doses and dispensing unsupervised doses and is intended to acknowledge the importance of a client /pharmacy relationship more than a per item payment.
Pharmacists are required to complete a Payment Claim Form per month (Appendix E), stating the number of patients and submitted to Primary Care Contracts on monthly basis. These should be submitted by the 15th day following the end of the month. Payment will be made on a quarterly basis.
7. Termination of contract
This agreement may be terminated by either party by giving three months written notice.

APPENDIX A

Shared Care 4 Way Treatment Agreement 1 of 2

This agreement is between the patient: ……………………………………………………………

GP……………………………………. Contact Number……………………………………….

Drug Worker………………………… Contact Number……………………………………….

Pharmacist…………………………… Contact Number………………………......

GPs are not obliged to prescribe methadone, but may do so as part of the planned treatment programme involving reduction and detoxification of the patient over a negotiated period supported by a worker from a drug agency.

Patient: I agree to:

1.Be polite and reasonable to all staff and patients at the surgery, pharmacy and agency.

  1. Attend all appointments with the GP and drug worker, as arranged. I will not miss appointments, or be late, without prior notice.
  2. Use my prescriptions only for personal use and will not share or sell any of my prescription.
  3. Participate in reviews to discuss progress and changes in treatment plan.
  4. Be honest and truthful about illicit drug use and work towards stopping my use of………………………..over an agreed period of time.
  5. Provide random urine screens for screening when asked to do so.
  6. Take responsibility for my own prescription and medication which will not be replaced.
  7. Give at least 10 days notice prior to any change in circumstances, e.g. holiday, change in address.
  8. I will not bring drugs or alcohol to appointments and will not attend appointments intoxicated.
  9. Take my medication as agreed.

Signed…………………………………………….Date……………………

Doctor: I agree to:

1. Treat the patient with due care and respect at all times.

  1. Provide primary health care as appropriate.
  2. Liaise with pharmacist.
  3. Contribute to regular reviews to discuss progress, problems and all changes in medication.
  4. Inform the drug worker of any significant changes or developments relevant to the treatment plan.
  5. Identify another GP at times of absence to cover any patients in the shared scheme.

Signed ……………………………………………Date………………….

Shared Care 4 Way Treatment Agreement 2 of 2

Drug Worker: I agree to:

1. Treat the client with due care and respect at all times.

  1. Meet the client at agreed intervals.
  2. Attend regular reviews to discuss progress, problems and changes in medication.
  3. Liaise with the GP and pharmacist.
  4. Respect the client’s confidentiality within the bounds of the agency policy.

Signed……………………………………………Date……………………..

Pharmacist: I agree to:

1. Treat the client with due care and respect at all times.

  1. Liaise with drug worker and GP as appropriate.
  2. Respect the client’s confidentiality.
  3. To inform the drug worker if there are any concerns regarding the prescription arrangements.
  4. To inform the drug worker if prescription is not collected each day.

Signed……………………………………………Date…………………….

PLEASE NOTE:ANY BREACH OF THIS AGREEMENT WILL RESULT IN A REVIEW OF YOUR TREATMENT. THIS AGREEMENT ACTS AS A CONFIDENTIALITY WAIVER.

1

Appendix B

Shared Care 2 Way Treatment Agreement (1 of 1)

This contract is between:

The patient: ……………………………………………………………

Pharmacist……………………………………………………......

GPs are not obliged to prescribe methadone, but may do so as part of the planned treatment programme involving reduction and detoxification of the patient over a negotiated period supported by a worker from a drug agency.

Patient: I agree to:

  1. Be polite and reasonable to all staff and patients at the surgery, pharmacy and agency.
  2. Attend all appointments with the GP and drug worker, as arranged. I will not miss appointments, or be late, without prior notice.
  3. Use my prescriptions only for personal use and will not share or sell any of my prescription
  4. Participate in reviews to discuss progress and changes in treatment plan.
  5. Be honest and truthful about illicit drug use and work towards stopping my use of………………………..over an agreed period of time.
  6. Provide random urine screens for screening when asked to do so.
  7. Take responsibility for my own prescription and medication which will not be replaced.
  8. Give at least 10 days notice prior to any change in circumstances, e.g. holiday, change in address.
  9. I will not bring drugs or alcohol to appointments and will not attend appointments intoxicated.
  10. Take my medication as agreed.

Signed…………………………………………….Date……………………

Pharmacist: I agree to:

  1. Treat the client with due care and respect at all times
  2. Liaise with drug worker and GP as appropriate.
  3. Respect the client’s confidentiality.
  4. To inform the drug worker if there are any concerns regarding the prescription arrangements.
  5. To inform the drug worker if prescription not collected each day.

Signed……………………………………………Date…………………….

PLEASE NOTE: ANY BREACH OF THIS AGREEMENT WILL RESULT IN A REVIEW OF YOUR TREATMENT. THIS AGREEMENT ACTS AS A CONFIDENTIALITY WAIVER.

Appendix C

Wiltshire PCT

Contact Information

Contractual issues:

Chris Phillips

Primary Care Contracts Manager

Wiltshire PCT

Southgate House

Pans Lane

Devizes

SN10 5EQ

01380 733757

Prescribing / Medicines Management:

Joanne Clarke

Medicines Governance Pharmacist

Wiltshire PCT

Southgate House

Pans Lane

Devizes

Wilts

SN10 5EQ

01380 733881

DAAT Lead:

The DAAT Office Administrator

Wiltshire County Council

Court Mills

Polebarn Road

Trowbridge

BA14 7EQ

01225 776890

For Specialist Drug and Alcohol contacts and User Networks etc. see the “Wiltshire Directory of Drug and Alcohol Services” available at:

Appendix D

Service Protocol for Supervised Administration (Consumption of Prescribed Medicines)

Initiating Supervision

When it is decided that supervised consumption is required, the prescriber or key worker will contact the patients chosen pharmacy. The prescriber/key worker will also explain to the patient that supervised consumption will be a requirement of treatment.

The prescriber will issue a prescription that complies with legal requirements, stating that consumption will be under supervision and giving details of weekend take home doses.

Prescription wording:

Please supervise consumption

Instalments due on days when the pharmacy is closed should be dispensed on the day IMMEDIATELY prior to closure

The pharmacy will discuss the process with the patient and both should review and sign the 2-way agreement or the 4-way agreement if provided.

Supervision of prescribed medicines

Supervised consumption should take place in a designated area of the pharmacy, which allows privacy. The process should be as discreet and efficient as possible, maintaining the patient’s dignity and saving the pharmacist time.

It is important that the dose is ready for the patient’s arrival.

On arrival in the pharmacy the identity of the patient should be checked, the patient should be allowed to check the name and quantity of their prepared dose.

The pharmacist should be satisfied that they are not ill or intoxicated. If the pharmacist considers the patient is grossly intoxicated the dose will be withheld and the key worker or prescriber contacted. Inappropriate behaviour in the pharmacy will also be notified to the patients key worker.

Doses should be taken and supervised as appropriate for the particular drug to ensure the drug is fully ingested before leaving the premises.

Paper cups should be rinsed and discarded. Dispensing bottles may be re-used for the same patient for one week. If the patient has drunk from the bottle it should be rinsed, the label removed and the bottle discarded.

Doses taken away

Doses taken away for the pharmacy closed days should be in a labelled container with a child resistant closure if appropriate. If more than one dose of a liquid is put in a container it is important to give the patient a suitable measuring devise to ensure they can accurately measure their daily dose.

Prescriptions ending

Inform the patient when their current prescription is coming to an end. A reminder from you will help to ensure that the drug agency and GP appointments are kept. It also avoids problems when a patient tries to collect a prescription which is finished. The pharmacist should check the continuity of scripts and contact the relevant prescriberif scripts are missing.

Missed Doses - Methadone

Pharmacists should suspend instalments of methadone if more than three days have elapsed since their last instalment was due. The pharmacist should contact the prescribing doctor and/or keyworker immediately to inform them and instruct the patient to attend their service.

Missed Doses - Buprenorphine

In the case of missed doses of buprenorphine the pharmacist should contact the prescribing doctor and/or keyworker immediately to inform them if the patient’s instalment is three or more days late, but may continue to dispense instalments from the date of attendance, up to 7 days from the last day that an instalment was dispensed.

Cessation of supervision

Planned cessation of supervision can only be made with direct prior agreement between the pharmacy and the prescriber/key worker. Pharmacists will maintain close links with prescribers and key workers.

When cessation is pharmacy initiated due to a breach of contract, the prescriber and key worker must be notified immediately.

Records

Record should be kept daily in the CD register, the prescription and the patient PMR.

In addition to the legal requirements of Patient Medication Records and Controlled Drugs Register, the pharmacist will put in place a means to recording the following details: name of the key worker, details of interventions with treatment services, date of birth, MUR offered and missed doses of each patient.

Drug Specific Issues

Buprenorphine

For Buprenorphine (Subutex), each days does should be packed separately, do not put a weeks supply in one box and pop a tablet out daily (Pharmaceutical Society).

The tablets should be removed from their foil into a paper cup for the patient to place in their mouth.

The tablets take up to 10 minutes to dissolve in the mouth, though it is thought that most of the active ingredient is absorbed in the first 3 minutes. Offering a drink of water before the tablet is put under the tongue can accelerate the process.

After the dose has been swallowed, the pharmacist should offer a drink of water to the client – this ensures that the does has not been held in the mouth. A sticky residue may remain which contains no active ingredients.

Methadone

Daily doses should be prepared in advance of the patient’s arrival. The daily amount should be measured, checked and poured into a container, capped and labelled. When the pharmacy is open, prepared does may remain out on the dispensary bench under supervision of the pharmacist.

After the dose has been swallowed, the pharmacist should offer a drink of water to the client – this ensures that the dose has not been held in the mouth and also serves to remove the sucrose content of the methadone mixture from the patient’s teeth. If the patient declines a drink it is helpful to engage in conversation to ensure the dose has been swallowed.