NHS Borders Enhanced Service Programme for Primary and Community
Care
Local Enhanced Service for DMARDs 2014 -15
(previously known as Near Patient Testing)
Important changes to DMARDs LES 2014-15
● Introduction of the Scottish Patient Safety Programme (SPSP) ‘DMARDs Care
Bundle’ with data collection for the DMARDs LES
● Changes to DMARDs list to include newer ‘MAB drugs
● Annual update of DMARDs LES drug list (i.e. no in-year additions)
Introduction
The treatment of several diseases within the fields of medicine, particularly in
rheumatology, is increasingly reliant on drugs that, while clinically effective, need
regular blood monitoring. This is due to the potentially serious side-effects that
these drugs can occasionally cause. It has been shown that the incidence of
side-effects can be reduced significantly if this monitoring is carried out in a wellorganised way, close to the patient’s home.
Aims
The DMARDs (Disease Modifying Anti-Rheumatic Drugs) Near Patient Testing LES is
designed to be one in which:
(i) therapy should only be started for recognised indications for specified lengths
of time
(ii) maintenance of patients first stabilised in the secondary care setting should
be properly controlled
(iii) the service to the patient is convenient
(iv) the need for continuation of therapy is reviewed regularly
(v) the therapy is discontinued when appropriate
(vi) the use of resources by the National Health Service is efficient
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Changes to DMARDs List
It is appreciated that over time the drugs utilised in a disease modifying manner
will change as newer medications become available and older preparations
cease to be used. Therefore on an annual basis newer drugs may be added to
the list. This is expected to be a ‘cost-neutral’ process as the total patient pool
will remain relatively static, only their medication will change.
Service outline
Health Improvement Scotland has set out the safety bundle for the safe and
efficient provision of near patient monitoring of certain drugs. The list of included
drugs shall include those agreed upon in the 2004 LES together with newer drugs
requiring primary care participation but not currently included in a NPT NES/LES.
This enhanced service will fund practices to provide that monitoring in a safe
and acceptable way that is a shared care drug monitoring service in respect of
the following specified drugs:
New DMARDs added to list for 2014 – 15:
1. Adalimumab
2. Certolizumab
3. Ustekinumab
4. 6 mercaptopurine
and the existing DMARDS List of:
a) Acitretin
j)
Etanercept
b) Amiodarone
k) Erythropoietin
t) Penicillamine
c) Amisulpride
l)
u) Quetiapine
d) Aripiprazole
m) Hydroxychloroquine
v) Risperidone
e) Auranofin
n) Leflunomide
f) Azathioprine
o) Methotrexate
w) Sodium Aurothiomalate
(Myocrisin)
g) Ciclosporin
p) Methotrexate i.m.
Hydroxycarbamide
h) Cyclophosphamide q) q) Mycophenolate
i)
Denusomab
r) r) Neotigason
s) Olanzapine
x) Sulphasalazine
y) Other ‘Salazines’
(5-ASA compounds)
z) Tacrolimus
ai) Tocilizumab
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(ii) a register. Practices should be able to produce and maintain an up-to-date
register of all shared care drug monitoring service patients, indicating patient
name, date of birth and the indication for treatment.
(iii) call, recall and testing. To ensure that systematic call and recall of patients
on this register is taking place either in a hospital or general practice setting.
The practice will also ensure that the relevant investigations for the particular
drug are performed each time the patient is seen as decided by the consultant
initiating the medication.
At the time of testing the patient should be asked regarding any possible side
effects.
The practice will also ensure that appropriate action is taken and documented
in the clinical record for any abnormal results from these tests.
Prior to providing an ongoing prescription the practice will ensure that the
relevant blood tests have been reviewed.
(iv) education and newly diagnosed patients. To ensure that all newly
diagnosed / treated patients (and / or their carers when appropriate) receive
appropriate education and advice on management of and prevention of
secondary complications of their condition. This should include written
information where appropriate
(v) continuing information for patients. To ensure that all patients (and/or their
carers and support staff when appropriate) are informed of how to access
appropriate and relevant information
(vi) professional links. To work together with other professionals when
appropriate including secondary care colleagues.
(vii) record keeping. To maintain adequate records of the service provided.
(viii) training. Each practice must ensure that all staff involved in providing any
aspect of care under this scheme have the necessary training and skills to do so
(ix) monitoring and measurement: Practices are required to carry out continuous
improvement monitoring against the evidence based SPSP DMARDs Patient
Safety DMARDs Care Bundle (a combination of measures developed by Health
Improvement Scotland - see Appendix for details of the bundle content and
rationale). Practices are required to carry out monitoring on a monthly basis,
each time choosing a random selection of 10 patients from their DMARDs
register. There is an option to use an embedded random number generator
within the monitoring sheet itself. Alternatively, if required, practices can use a
free online randomiser tool (press ctrl + click over link to access). This tool
generates a random set of numbers from your practice DMARDs register to
identify patients on which to carry out the bundle testing each month. Enter 1 in
first box, 10 in second and in the integer range add 1 in the first box then the
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number of DMARDs patients on your register in the second box then scroll down
to Step 3 and press ‘Get Sets’.
Practices should use the Data Collection Tool & Excel Spreadsheet in Appendix
to compare each of 10 patients against the DMARDs care bundle measures and
to record whether or not they are compliant. Practices are then required to
submit an electronic copy of this information on a monthly basis to P&CS.
Please e-mail a copy of the spreadsheet to:
[email protected] by the 5th of the following month
Practices should use the data to reflect upon and where necessary hone internal
processes to ensure reliable systems are in place ensuring harm free DMARDs
care is delivered.
Untoward events
It is a condition of participation in this LES that practitioners will undertake a
Significant Event Analysis (SEA) for any hospitalization or death occurring
because of a patient being treated by any of the above named medications.
Duration of treatment
It is appreciated that not all patients will remain on these medications for the full
12 months of Enhanced Service duration: some will cease to receive the
medication before the year finishes and others will commence treatment part
way through the year. It is the intention of the Enhanced Service to recognise the
workload these patients have on a practice and all such patients receiving
these medications shall be remunerated irrespective of their duration of
treatment.
Funding
It is expected that for this Enhanced Service practices will be operating at either
a level 2 or 3 payment level.
In Level 2 activity, the practice will:

Call / recall the patient at the appropriate time.

Utilise NHS Borders funded phlebotomy re: required blood samples/tests

Have those samples analysed at the Hospital Laboratory

Act on the results so received by either
o
Continuing to prescribe the medication as previously advised or
o
Liaising with the relevant Secondary Care colleagues regarding
any suggested changes.
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In Level 3 activity, the practice will:

Call / recall the patient at the appropriate time.

Take the required blood samples / tests

Have those samples analysed at the Hospital Laboratory

Act on the results so received by either
o
Continuing to prescribe the medication as previously advised or
o Liaising with the relevant Secondary Care colleagues regarding
any suggested changes.
The level of payments offered for 2014 – 15 will be:
£ 95.90 per patient per year for Level 2 activity
£106.56 per patient per year for Level 3 activity
In addition practices will receive a fee of £500 to cover the administration costs
associated with data collection and submission relating to the Patient Safety
element of the service.
Reporting and Returns
Practices are required to report on DMARDs Near Patient Testing activity on a
quarterly basis, on the NHS Borders GMS2 Quarterly Enhanced Services Activity
Return form, already in use for other Enhanced Service returns such as Minor
Surgical procedures.
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APPENDIX
1. DMARDs Bundle and Rationale
The following attachment details the specific measures included in the Health
Improvement Scotland (HIS) DMARDs Patient Safety Bundle and the rationale
and evidence behind use of these in practice:
DMARD safety
bundle
2. DMARDs Data Collection Tool and Patient Safety Return Spreadsheet
Practices are required to submit their completed Excel spreadsheet on a monthly
basis to P&CS.
Please e-mail an up-to-date copy of the DMARDs monitoring sheet to:
[email protected] by the 5th of the following month
DMARDs monitoring
sheet
Please note:

When opening the Excel monitoring sheet document, choose ‘enable
macros’ to allow for full functionality.

The monitoring sheet contains a button linking to a random number
generator on each monthly reporting sheet. For this to work, you must
enter the total no. of patients on DMARDs that month in the bottom left
green box (and press enter) then click on the ‘Generate random numbers’
button.

Even if there are already numbers populating the ‘total no. on DMARDs’ or
random no. boxes, press ‘Clear All’, then enter your practice total no.
(remembering to press enter) and then you will be able to generate new
numbers each month, as above.
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Please sign and return this completed form only to confirm your
participation.
NHS Borders Enhanced Service Programme for
Primary & Community Services
NHS Borders Local Enhanced Service 2014/15
For DMARDs
(Previously known as Near Patient Testing)
Practice Name: _____________________________
Practice No: ______________________________________________
Signed for and on behalf of the Practice _____________________________
Please print name and designation __________________________________
Date _______________________________________________________________
Notice Period
In the event of a practice being unable to maintain the service for the
duration of the contract or wishing to opt out, an appropriate period of
notice will be agreed with NHS Borders (normally 3 months).
The payments will be subject to the normal payment verification
processes.
Forms should be returned to Louise Patterson-Coltman in P&CS.
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