Practice Name:
Coastal West Sussex
Clinical Commissioning Group
Practice Address:
Specification for a Locally Enhanced Service to support DVT
Assessment and Treatment in Coastal West Sussex
Introduction
Practices are expected to provide all essential and additional services that they are contracted to provide to all their
patients. This local enhanced service specification outlines the more specialised health care services to be provided
to patients with suspected Deep Venous Thrombosis (DVT). No part of this specification by commission omission or
implication defines or redefines essential or additional services.
This service must be provided in a way that ensures it is equitable in respect of race, creed, culture, diversity,
disability and age.
Background
Suspected Deep Venous Thrombosis (DVT) is a significant source of attendance at Western Sussex Hospitals NHS
Trust (WSHT) and the diagnosis of a DVT is only confirmed in 1 in 6 of referred cases. Effective assessment tools (risk
assessment guidelines and D-Dimer test kits) can be safely used within primary care to determine where the
probability of DVT is unlikely, thus reducing unnecessary referrals.
Coastal Clinical Commissioning Group and Western Sussex Hospitals Trust have agreed this specification to improve
our services for patients in Coastal CCG.
Aims and Objectives
The overall objectives of the service are to develop a primary care / outpatient DVT assessment service that is
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clinically safe
more convenient for patients
cost effective
Service Outline
Patients presenting to general practice with a suspected DVT will be assessed using the agreed assessment tool
below.
A. Patients with a higher probability of DVT (score of 2 or more) will be referred (via One Call) to the clinical
nurse specialist at WSHT to discuss ultrasound and immediate management
B. Patients with a score of 0 or 1 on the assessment tool will have a D-Dimer test. This should preferably be
done using near patient testing kits within the practice.
(Note: If the practice does not have access to these then a blood sample should be taken and sent to the
WSHT lab for urgent processing) If the D-Dimer shows a negative score, DVT should be ruled out and
another diagnosis sought.
If DVT is suspected (Score 2 or more or Score 1 + positive D-Dimer) the clinician should
1. Assess the patient for risk of bleeding (if high risk, consider admission)
2. Discuss the case with the clinical nurse specialist to agree and arrange next steps
3. Where appropriate, arrange administration of the first dose of LMWH and any subsequent doses until the
scan
4. Fax or email the standard referral form (Appendix ...) to One Call 01903 285092 or [email protected]
Scans and, where necessary, transport will be arranged and booked by One Call
Clinical pathway and guidance
Please find the assessment flowchart at Appendix ... and clinical guidance at Appendix ...
CLINICIANS PLEASE NOTE THAT THE FOLLOWING SHOULD BE REFERRED TO SECONDARY CARE
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SUSPECTED PULMONARY EMBOLISM (PLEASE NOTE THERE IS NO PLACE FOR D DIMER TESTING IN THE
COMMUNITY IN SUSPECTED PULMONARY EMBOLISM)
PREGNANCY/POSTNATAL
SIGNIFICANT COLOUR CHANGE
INVOLVEMENT OF THE WHOLE LEG
HIGH RISK OF BLEEDING
In patients with a positive scan, confirming the diagnosis of DVT, secondary care will
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
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2
Formulate the treatment plan
Advise and communicate the plan with the patient
Refer to the next anticoagulation clinic (where appropriate)
Request any appropriate additional investigations


Receive and act appropriately on the results of any additional investigations (which may include asking the
GP to follow up investigations or referring on to the appropriate speciality, if appropriate, in line with agreed
local consultant to consultant referral guidance)
Provide timely information to the GP
Consumables
D-Dimer kits:
We wish to encourage near patient testing and this is reflected in the fee structure. The practice is responsible for
the supply of D-Dimer kits. There are various manufacturers & suppliers of D Dimer near patient testing kits. Some
of these are listed below
The manufacturer’s instructions and advice on use of the kits should be followed in all cases
http://www.oberoi-consulting.com/products-d-dimer-kits/
http://www.d-dimer.co.uk/simpliRED.asp?navid=3
http://www.alere.co.uk/nhs-health-checks/clearviewr-simplify-d-dimer-43/product-listing.htm
LMWH:
The practice can either keep its own small supply in stock or make arrangements with a nearby pharmacy to ensure
a supply will be available if required. The cost of practice supplied LMWH will be reclaimable through the self
administered item mechanism. Practices should prescribe the LMWH of choice as per the local formulary.
Eligibility to provide the service
The practice must adhere to the agreed assessment tool detailed in the pathway diagram (appendix 1), and
treatment guidelines which may be updated periodically.
Staff undertaking diagnostic tests, assessments and initiating and administering treatment must be adequately
trained and supervised as determined by the Practice.
The National Patient Safety Agency provides support materials which can be adapted locally which include
workforce competency statements on administering heparin therapy. The ‘Preparing and Administering Heparin’
competency can be viewed at
www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60026&type=full&servicetype=Attachment
The Practice must have adequate mechanisms and facilities, including premises and equipment, as are necessary to
enable the proper provision of this service.
3
Payment
Practices should claim monthly using the enhanced service multi-claim form.
Practices will be paid one or both of 2 fees:


Fee A: one fee for assessment that includes near patient D-Dimer testing (note this does not include DDimer tests done through WSHT laboratory)
Fee B: one fee for any course of LMWH therapy (regardless of length)
There are therefore 4 possible outcomes of an assessment in primary care, as follows
Outcome 1
Near patient D-Dimer
performed
Fee A £58.34
£
Outcome 2
Near patient D-Dimer
performed
+
LMWH administered
and/or patient trained
to administer
Fee B £82.35
£
Outcome 3
Outcome 4
LMWH administered
Assessed and
and/or patient trained to referred
administer
Fee C£24.01
£
Suggested Read codes
9kg
9kg0
9kg1
9kg2
4
DVT – enhanced service administration
DVT stage 1 service level – enhanced service administration
DVT stage 2 service level – enhanced service administration
DVT stage 3 service level – enhanced service administration
No fee
n/a
Verification
For verification purposes, adequate records will need to be maintained at the practice to provide an audit trail for
post payment verification purposes. The CCG may routinely check practice held information at any time without
warning to satisfy the requirements of this service specification.
Disputes
In the event of disagreement or dispute, the CCG and the practice will use best endeavours to resolve the dispute
without recourse to formal arbitration. If unsuccessful, the matter will be determined in accordance with the
normal contractual dispute resolution procedure.
The costs of any adjudication will be borne by the unsuccessful party to the dispute.
In the event of contractual issues, failure outside of the formal notification by either partner this will be covered by
the CCG disputes procedure as per nGMS. In the event of failure to deliver against the agreed standards both
parties can instigate procedures for a breach.
The CCG may terminate the agreement where there is evidence of failure to comply with the agreement. Normally
the notice period will be three months, however in exceptional circumstances the CCG reserves the right to give no
notice, but will consult with the LMC and the practice concerned.
The CCG will only invoke the termination clause one all reasonable efforts have been made to resolve disputes
locally. The agreements may be terminated by the practice or the CCG, by giving three months notice of their
intention to withdraw from the scheme subject to the provision of above paragraph.
Practice declaration:
The practice has understood the terms of the service and is seeking to provide a service on this basis. The
practice will adhere to the terms of the contract and agrees to provide the monitoring information as specified
on request.
Signed on behalf of Practice
GP Name (Print)……………………………
Date………..…………………
GP Signature………………………………………
Signed on behalf of the CCG
……………………………………………
GP Services Lead
5
Date: ……………………
Appendix 1:
Appendix2:
Appendix 3:
6
Primary Care DVT Assessment Tool and Pathway
Supporting Clinical Guidance
Referral Form