Bath, Gloucestershire, Swindon

& Wiltshire Area Team

Enhanced Service ForThe Provision of Palliative Care Community Pharmacy Services in Normal Hours

Service Level Agreement (SLA) 2014-2015

1.Introduction

2.Signatures

3.Aims and Objectives

4.Service Specification

5.Process - Pharmacy Contractors

6.Quality Indicators Pharmacy Contractors

7.Quality Indicators PTC

8.Financial Details

9.Monitoring Arrangements

10.Termination of Contract

Appendix A - Palliative Care Drugs Scheme List of Drugs stocked

Appendix B – Claim Form for Retainer.

AppendixC – Claim Form for Supplies for Palliative Care Provision

  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.

  1. 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 1stApril 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:
  1. Aims and Objectives

This service aims to ensure that palliative care medicines are available during normal working hours.

  1. Service Specification
  2. 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
  3. 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.
  1. Process- Pharmacy Contractors
  2. The pharmacist will
  3. 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.
  4. Agree to participate in any audit of the scheme as necessary to ensure stocks are available as stated.
  5. The contractor will inform the Area Team if they have been unable to supply the medication.
  6. Submit the dispensed prescription to the PPD in the normal way.
  7. 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.
  8. Use his/her professional judgement and take sole responsibility for any supply made outside the specification set out in this service level agreement.
  1. Quality Indicators Pharmacy Contractors
  2. 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.
  3. The pharmacy contractor reviews its Standard Operating Procedures and the referral pathways for the service on an annual basis.
  1. Quality Indicators Area Team
  2. The Area Team will
  3. Ensure all pharmacies, GPs, nurses and palliative care providers within the locality are made aware of the pharmacies providing the Enhanced level of service.
  4. Supply local palliative care guidelines.
  5. 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.
  1. Financial Details
  2. A £210 per annum retainer fee will be paid to the pharmacy contractor participating within the scheme.
  3. There will be a pro rata payment (£17.50 per month) for pharmacies that join the service part way through the financial year.
  4. 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).
  5. 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.
  6. The retainer can be claimed on submission of a Claim Form (Appendix B).
  7. 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.
  1. Monitoring Arrangements
  2. The Area Team will periodically monitor the stock levels held by pharmacies.
  3. The Area Team will also monitor any claims for date expired stock.
  1. 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 / Quantity
Cyclizine 50mg/ml Inj / 10x1ml
Dexamethasone 4mg/ml Inj / 10x2ml
Diamorphine 10mg inj / 10
Diamorphine 30mg inj / 10
Diamorphine 100mg inj / 10
Diazepam 5mg/ml Inj / 10x2ml
Glycopyrronium Bromide 200mcg/ml inj / 10x1ml
Haloperidol 5mg/ml inj / 5x2ml
Hyoscine Butylbromide 20mg/ml inj / 10x1ml
Hyoscine Hydrobromide 400mcg/ml inj / 10x1ml
Levomepromazine (Methotrimeprazine)25mg/ml inj / 10x1ml
Metoclopramide 5mg/ml inj / 12x2ml
Midazolam 2mg/ml inj / 10x5ml
Octreotide 50mcg/ml inj / 5x1ml
Octreotide 100mcg/ml / 5x1ml
Sodium chloride 0.9% inj / 10x10ml
Phenobarbital 200mg/ml inj / 10
Water for injection / 10x10ml
Domperidone 30mg Suppositories / 10
Diclofenac 100mg Suppositories / 10
Diazepam 10mg Rectal Tubes / 5
Prochlorperazine 25mg Suppositories / 10
Oramorph Oral Solution 10mg/5ml / 1x100ml
Oramorph Concentrated Oral Solution 100mg/5ml / 1x30ml
Morphine sulphate 10mg/ml inj / 1x5
Morphine sulphate 15mg/ml inj / 1x5
Morphine sulphate 30mg/ml inj / 1x5
Oxycodone 10mg/ml 1ml inj / 1x5
Oxycodone 10mg/ml 2ml inj / 1x5
Oxycodone liquid 5mg/5ml / 1x250ml
Oxycodone concentrate 10mg/ml / 1x120ml
Fentanyl 12 Patch / 1x5
Fentanyl 25 Patch / 1x5
Fentanyl 75 Patch / 1x5
Fentanyl 100 Patch / 1x5
Naloxone 400mcg/ml inj / 10x1ml

Appendix B – Claim Form for Retainer

Claim for Retainer Fee

Palliative Care Provision

Retainer Fee forApril 2014 to 31st March 2015

Please provide contact details for the out of hours period

Name of Pharmacist to Contact:

Telephone number:

I claim £210retainer feefor 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 NamePosition

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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AppendixC – Claim Form for Supplies for Palliative Care Provision

Claim for Reimbursement of

Expired Stock for the

Palliative Care Provision Service

Details of Expired Stock / Batch Number / Expiry Date / Amount Payable
£
£
£
£
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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