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1
Index
Summary of the scheme
3
Service Level Agreement
4
Pharmacy Client Letter
8
Pharmacy Discharge Letter
9
Client Record of Supply Form
10
Claim form (SC1)
11
NRT Guide
12
Contact details
Stop Smoking Wales
0800 0852219
Local Stop Smoking Wales Advisors
Flintshire – Rachel Cooper, Nia Thomas
Victoria Jaffray & Gavin Jones
0800 0852219
Medicines Management Team
Simon Gill
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01352 803384
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Summary of the Scheme
Patient attends
Stop Smoking Wales (SSW) for
6 week behavioural course.
Pharmacy client letter issued with
information on NRT products and smoking status.
Intended quit date is week 2.
Patient attends Pharmacy.
Pharmacist responsible for ensuring
NRT supplies are suitable for the patient
2 weeks supply provided.
Verbal advice and support given



Referral to
GP
Client letter retained in pharmacy.
Client record of supply form completed
Claim form SC1 completed.
Form to be submitted monthly to LHB
Patient returns to SSW.
Further pharmacy client letters issued.
At week 6 a pharmacy discharge letter will be issued.
Following receipt of the discharge letter, further supplies may
be made up to a maximum of 12 weeks
YES
Retain letters and client
record of supply form in the
pharmacy.
Client completed
treatment period
up to 12 weeks
AND QUIT or lost
to follow up?
NO
No further supply can be
made under the scheme. If
patient wishes to continue
NRT refer to GP for
continued supplies
Remember
ASK if the patient is a smoker, or still smoking
ADVISE them of the personal health benefits in quitting
ACT - refer them to Stop Smoking Wales
Pharmacy staff are in an ideal position to refer clients to SSW who may
then return to the pharmacy for their NRT as part of this scheme.
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Local Enhanced Service
Smoking Cessation Enhanced Service Level 2
Service Level Agreement (SLA) 2009/10
This service is designed to link community pharmacy with the intensive
behavioural support service provided by Stop Smoking Wales (SSW).
Under this arrangement the community pharmacist will undertake to
supply NRT to smokers who are receiving intensive smoking cessation
behavioural support from SSW, in response to a referral letter that
indicates the client’s dependence on nicotine.
1. Scheme Eligibility
1.1. A pharmacy wishing to provide this service shall apply to the LHB in
writing. Only those pharmacies located within and commissioned by
Flintshire Local Health Board to provide a level 2 smoking cessation
service will be eligible for payment.
1.2. Agreement period – this will commence in September 2009 and end
on 31st March 2010. It will be subject to renewal if agreed by all
parties.
1.3. Premises – the service can only be provided in a registered pharmacy,
which must have a suitable area for consultation with clients. This can
be a quiet area within the pharmacy rather than a separate room.
1.4. If requested the pharmacy will be required to display appropriate
smoking cessation material designated by the LHB.
2. Service to be provided
2.1. Clients will present to the pharmacy after assessment by a SSW
specialist or smoking cessation practice nurse.
2.2. The SSW specialist/practice nurse will provide the client with a
referral form indicating the NRT that the client has expressed an
interest in, together with their current smoking status (see pharmacy
client letter).
2.3. SSW specialists are only able to provide clients with details of NRT
products available. They are not able to assess a client’s medical
history or make any recommendations with respect to strength and
quantity of NRT.
2.4. If considered appropriate, the pharmacist should supply NRT via the
SSW approved referral form and advise the client on its use. The
pharmacist will check for any potential interactions with any known
prescribed or OTC medicines and any contraindications on use. The
pharmacist will reach a decision on the most appropriate product to
be supplied by reference to the pharmacy PMR and through
discussion with the client.
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2.5. As the client’s circumstances may change between supplies the
pharmacist is required to review the appropriateness of the product
prior to each supply of NRT.
2.6. If the supply is considered to be inappropriate the client should be
referred to their GP for further consultation. SSW will make sure that
clients are aware that the final decision to supply will rest with the
pharmacist / or GP.
2.7. The supplying pharmacist is responsible for ensuring that all supplies
are within the product license.
2.8. Each supply of NRT should only be for a 2 week period upon receipt
of the referral letter from SSW.
2.9. Supply should normally be made within 2 weeks of seeing the
specialist.
2.10.The treatment period will vary for each individual client but can last up
to 12 weeks.
2.11.Stop Smoking Wales will inform the pharmacy by letter when the
client has completed the behavioural programme of smoking
cessation, so that the pharmacist may continue to provide NRT to
complete the course (see Pharmacy client discharge letter)
2.12.Supply should normally be made to the client in person, but can be
made to a representative if prearranged.
2.13.To prevent fraud all packs of products supplied should be marked
indelibly with NHS. Only original packs are to be supplied containing
a patient information leaflet. This ensures compliance with EC
labelling and leaflet directive 92/27.
2.14.Verbal advice and information about smoking cessation must be
given with each supply of NRT.
2.15.Supply must be made by the pharmacist and details of strength and
quantity recorded on the client’s record of supply form. BOTH
CLIENT AND PHARMACIST MUST SIGN AND DATE THE FORM
FOR THE SUPPLY GIVEN. The letters and the record of supply form
must be retained in the pharmacy.
2.16.Details of each supply must be recorded on Claim Form SC1
2.17.All supplies of NRT and other significant interventions must be
recorded on the pharmacies PMR system.
3. Training and Education
3.1. The contractor must nominate a pharmacist who is responsible for
ensuring that an SOP (relevant to their pharmacy) is in place for the
provision of this service.
3.2. Provided that the accredited pharmacist has established systems
supplies may be made by any pharmacist including locums.
3.3. Clients do not need to complete a consent form at the pharmacy as
this will have been done by the SSW.
3.4. The accredited pharmacist must ensure that support / relief
pharmacists and locums are trained to provide continuity of service in
their absence.
3.5. The accredited pharmacist and other pharmacists providing the
service must complete the WCPPE distance learning pack ‘A – Z of
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Smoking Cessation’ and have attended the LHB level 2 smoking
cessation service training.
3.6. The pharmacist(s) running the service must be included on a list of
‘accredited pharmacists to operate the service agreement’ held by the
LHB/BSC.
3.7. The pharmacy contractor has a duty to ensure that all pharmacists,
locums, and staff have been adequately trained and follow the SOP.
4. Reimbursement
4.1. A copy of the ‘Local Health Board Audit and Claim Form (SC1)’ must
be submitted monthly, (no later than the 10th of the following month) to
the Prescribing Support Team, Flintshire LHB.
4.2. The LHB will pay a dispensing fee of £2 per supply of NRT.*
4.3. The cost of the NRT supplied will be reimbursed on the current Drug
Tariff price plus VAT (currently 5%).
* This fee will be subject to negotiations on the indicative rates for National
Enhanced Services for 2009/10. Once agreed the fee will be backdated to
the start of the scheme (September 2009).
5. Monitoring and Audit
5.1. An audit trail must be available at the approved premises for
inspection by the LHB authorised officer or officers acting on its behalf
by BSC Wales, auditors appointed by the LHB or the Wales Audit
Office. The SSW letters and “Client Record of Supply Form” are to be
kept at the pharmacy.
5.2. The LHB reserves the right to make audit checks without prior
notification.
5.3. By agreeing to this Service Level Agreement contractors are
consenting to the disclosure of relevant information for the purpose of
fraud prevention, detection and investigation.
5.4. Action can be taken against a contractor in the case of an incorrect
claim.
6. LHB Service Responsibilities
6.1. To work in partnership with Stop Smoking Wales and community
pharmacy to ensure effective communication and continuity of service.
6.2. To support the resolution of difficulties that may detract from the
efficient running of the service.
6.3. Will arrange at least one training event per year for pharmacies
providing the service if service levels or product specifications change.
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7. Termination of Contract
7.1. In the event of termination of the service the party terminating the
service will ensure a minimum of 90 days notice is provided to all
parties (including clients as necessary).
I/we declare I/we have read, understood, and will adhere to Flintshire
Local Health Boards - Pharmacy Smoking Cessation Enhanced Service
(Level 2), Service Level Agreement for 2009/10.
Agreement Period: From September 2009 to 31st March 2010.
Please complete and sign this form; return this original document to:
Medicines Management Team, Flintshire Local Health Board, Preswylfa,
Hendy Road, Mold, CH7 1PZ, please make a copy for your records:
Name of Pharmacy:________________________________________
Address of Pharmacy:______________________________________
________________________________________________________
Name of Pharmacist(s) providing this service:______________________
Pharmacist signature:__________________________ Date:_________
Designation:_________________________________
Name of Pharmacist(s) providing this service:______________________
Pharmacist signature:__________________________ Date:_________
Designation:_________________________________
…………………………………………………………………………………………..
Signed for and on behalf of Flintshire LHB
Name:______________________________________
LHB signature:_______________________________ Date:_________
Designation:_________________________________
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Pharmacy Client Letter
from Stop Smoking Wales
Date: ……………………
Dear Pharmacist
Client Name………………………………………………………… DOB: …../…../…….
Address
………………………………………………………………………………………………..
This letter is to confirm that the above client has committed to participating in the
Stop Smoking Wales support programme.
The client has informed us that he/she has smoked ………. cigarettes (or equivalent)
per day and has made ………………. previous serious attempts to quit.
His/her dependency on nicotine has been assessed as: (please circle)
high / medium / low
I have provided information on Nicotine Replacement products to the client and
he/she has expressed an interest in using the product/s circled below:
Nicotine replacement
therapy
24 hour patch
16 hour patch
Sub-lingual tablet
Inhalator
Lozenge
Gum
Spray
The client is currently at week ……… of their stop smoking programme.
Additional information:
……………………………………………………………………………….
…………………………………………………………………………………………………
I do not have this patient’s NHS medical records. In addition, I am not in a position to
assess this person for possible contraindications to any of the available smoking
cessation aids. I have explained that you may need to conduct an assessment prior
to making a decision.
Please consider the suitability of the above type of medication and supply
appropriate NRT, taking into account any contraindications and potential drug
interactions.
Stop Smoking Wales only provides clients with information on the products and how
to use them; it does not assess a client’s full medical history or make prescribing
recommendations.
Many thanks for your co-operation. If you have any queries please do not hesitate to
contact me on the number below.
Yours sincerely
Stop Smoking Specialist, Stop Smoking Wales
Tel: 0800 085 2219
REF: SSW Pharmacy CL V1
Stop Smoking Wales Service Pharmacy Client Letter
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17.12.08
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Pharmacy Client Discharge Letter
from Stop Smoking Wales
Date…………………………
Dear Pharmacist
Client Name……………………………….…………………….. DOB: ……/……/…….
Address…………………………………………………………………………....................
This letter is to confirm that the above client has successfully completed a six week
behavioural support programme with Stop Smoking Wales.
At the start of the programme, the client smoked ……….. cigarettes (or equivalent)
per day and quit smoking on ……………… Continued cessation has been monitored
by regular carbon monoxide readings.
The client is currently at week ………….. of their stop smoking programme. Please
continue to supply at 2 weekly intervals to complete the course in line with your
Local Health Board Service Level Agreement. Brief verbal advice and information
about smoking cessation must be given with each supply of NRT.
Additional information: ……………………………………………………………………….
………………………………………………………………………………………………….
Stop Smoking Wales only provides clients with information on the products and how
to use them. Specialists do not assess a client’s full medical history or make
prescribing recommendations.
Please contact me on the number below if you have any queries.
Yours sincerely
Stop Smoking Specialist
Stop Smoking Wales
Tel: 0800 085 2219
For pharmacy use only:
Please retain this letter in the pharmacy and supply the remainder of the course of NRT
where appropriate. Maximum of 6 weeks treatment: 2 week supply at 2 week intervals.
NRT
Week 7
Week 9
Week 11
Form
Strength
Quantity
Date
REF: SSW Pharmacy CDL V2
Stop Smoking Wales Service Pharmacy Client Discharge Letter
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Signature
07 05 2009
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Client Record of Supply Form
A letter will be issued by Stop Smoking Wales in preparation to quit at week 2. A further
letter(s) will be issued during the six week behavioural programme. At week 6 a discharge
letter will be issued. Supplies of NRT can be continued up to a maximum treatment period of
12 weeks. Please record each supply made for the client on the form below and keep this
with the letters received from Stop Smoking Wales.
Client’s Name:______________________________________
Pharmacist to assign client a Unique Reference
DOB:____________________
Number:_________________________
Date of
Supply
1st Product Supplied
(State Name, Strength,
Pack size)
2nd Product Supplied
(only complete if dual
treatment indicated in
Client Letter from Stop
Smoking Wales)
No of packs
supplied, of
each product
(max 2
weeks)
Client to sign
I confirm I have
received the products
& quantities listed to
the left
Signature of
supplying
pharmacist
Possible contraindications - For use by pharmacist.
No
Yes
History of recent cardiovascular disease
< 4 weeks
Phaeochromocytoma
These are absolute contraindications and this patient should be
referred to their GP.
Uncontrolled Hyperthyroidism
History of allergy to NRT products
Skin disorder e.g. psoriasis, eczema
Diabetes Mellitus
These are either contra-indications to
particular types of NRT or are
conditions where the client will need
additional advice on the use of the
NRT supplied by the pharmacist.
See letter from MHRA.
Pregnancy
Oesophagitis/gastritis/peptic ulcer
Breast feeding
Hepatic impairment
Renal impairment
These forms must be retained in the supplying pharmacy as required by the service specification. These form an audit
trail of claims at the premises, and the information on these claims may be subject to random validation by the LHB or
authorised officers. Action may be taken if the claims are seen to be incorrect.
www.stopsmokingwales.com
www.dimsmygucymru.com
Tel: 0800 085 2219
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Form SC1: Local Health Board Audit and Claim Form - Pharmacy Smoking Cessation
Enhanced Service (Level 2). Supply of NRT at the request of Stop Smoking Wales.
Pharmacy Stamp
Month of claim:__________________________
Name of Pharmacy:_______________________
Date Supplied
Address:_______________________________
Clients Unique
Name, Strength, Pack Size & Quantity
Drug Tariff
Reference
of NRT Supplied
Cost of NRT
Number
A) Total Cost of NRT at DT price =
B) V.A.T @ 5% of NRT cost =
C) Service fees = Number of items processed x £2.00=
Total cost of claim = A+B+C=
Pharmacy: To be completed by the Flintshire LHB accredited Pharmacist in accordance to the
Service Level Agreement.
I claim for a total of £………………… for the supply of nicotine replacement therapy as part of the LHB
Community Pharmacy Smoking Cessation Enhanced Service (Level 2).
Signed ________________________________________ Date
_____________________
Print
________________________________________ RPSGB number
_____________________
Claims to be made monthly, no later than the 10th of the following month. Return claims to:
Prescribing Support Team, Flintshire LHB, Preswylfa, Hendy Road, Mold, CH7 1PZ.
All claims may be subject to post-payment verification
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