FREEDOM OF INFORMATION REQUESTS MAY 2014 Request Foi Number: 55 Response RC’D 02 May 2014. Written FOI request from MP John Glen around Innovation and contracting. FOI number: 56 rc’d 06 May 2014 . 1. According to your current IVF treatment policy: According to your current IVF treatment policy: a. How many cycles of IVF do you offer to eligible patients? a. How many cycles of IVF do you offer to eligible patients? Two b. Do you fund a full cycle of IVF, as defined by NICE, which includes replacement of all frozen embryos? Yes c. What is your upper and lower age limit that female patients must Do you fund a full cycle of IVF, as defined meet in order to qualify for treatment? The woman intending to become by NICE, which includes replacement of all pregnant must be between the ages of 18 – 42 years. No new cycle frozen embryos? If not how many frozen should start after the woman’s 43rd birthday. embryo transfers do you fund? d. Do you fund one full cycle of IVF for women aged 40-42 in line with the NICE guidance? Women aged 40–42 years who have not conceived c. What is your upper and lower age limit after 2 years of regular unprotected intercourse or 12 cycles of that female patients must meet in order to artificial insemination (where 6 or more are by intrauterine qualify for treatment? insemination), will receive 1 full cycle of IVF, with or without ICSI, provided the following 3 criteria are fulfilled: d. Do you fund one full cycle of IVF for • they have never previously had IVF treatment women aged 40-42 in line with the NICE • there is no evidence of low ovarian reserve guidance? • there has been a discussion of the additional implications of IVF and pregnancy at this age. b. e. f. g. h. i. j. k. l. Do you have an age criteria that male e. Do you have an age criteria that male patients must meet in order patients must meet in order to qualify for to qualify for treatment? No treatment? If so, please state what the criteria is. f. What must the smoking status of patients be? Not stated in the policy What must the smoking status of patients be? g. What weight requirement exists (i.e. BMI)? The female patient’s BMI should be between 19 and 30 prior to referral to tertiary services What weight requirement exists (i.e. BMI)? h. How long do couples need to be trying to conceive before becoming eligible for treatment? Two years How long do couples need to be trying to conceive before becoming eligible for i. Is there a minimum period that the couple need to have been in a treatment? relationship before becoming eligible for treatment? Cohabiting couples must have been in a stable relationship for a minimum of 2 years to be entitled to Is there a minimum period that the couple treatment. need to have been in a relationship before j. What eligibility criteria do you apply in relation to existing children becoming eligible for treatment? that either one or both partners may have? Neither partner should have any What eligibility criteria do you apply in living children (this includes adopted children but not fostered) from that or relation to existing children that either one any previous relationship. or both partners may have? k. What policy is in place (if any) for the use of Single Embryo Transfer? Multiple births are associated with greater risk to mothers and What policy is in place (if any) for the use children and the HFEA therefore recommends that steps are taken by of Single Embryo Transfer? providers to minimize multiple births. This is currently achieved by only transferring a single embryo for couples who are at high risk. Do you fund fertility treatment for same l. Do you fund fertility treatment for same sex couples, and if so what sex couples, and if so what additional additional eligibility criteria do they have to fulfil? For same-sex couples the eligibility criteria do they have to fulfil? failure to conceive after twelve rounds of donor or partner insemination, of m. Do you fund fertility preservation for cancer which at least six will be carried out through IUI, in the absence of any known patients and if so what budget is the funding reproductive pathology. Six rounds of IUI treatment are expected to be selffunded in these circumstances taken from? 2. m. Do you fund fertility preservation for cancer patients and if so what What is the average cost of a cycle of an IVF budget is the funding taken from? These funding requests would come cycle funded by the CCG and what does that through the Individual funding request stream and would be dealt with on an include? individual case basis. 3. What providers does the CCG contract with to 2. What is the average cost of a cycle of an IVF cycle funded by the CCG and what does that include? £3,123 includes all procedures covered within provide IVF services? NICE Guidance. 4. When was the current assisted conception policy developed? And who was consulted? 3. What providers does the CCG contract with to provide IVF services? Contracts in place with Sheffield Teaching Hospitals and Leeds 5. When will the CCG review its assisted Teaching Hospitals conception policy? 6. 7. 8. 9. 4. When was the current assisted conception policy developed? And who Is the assisted conception policy available on the was consulted? October 2013 – Panel members are listed on the policy CCG’s website? If so please provide a link to the 5. When will the CCG review its assisted conception policy? Due for policy. review between Jan and March 2016 Please could you provide me with a copy of your 6. Is the assisted conception policy available on the CCG’s website? If so assisted conception policy? please provide a link to the policy. Not currently on the website. Which MPs cover the boundaries of the CCG? 7. Please could you provide me with a copy of your assisted conception policy? Please find the policy attached. I would also like to request permission to republish the data provided in a publically accessible 8. Which MPs cover the boundaries of the CCG? Please click the attached link for MP boundary information https://www.barnsley.gov.uk/about-us/howdocument/web-format. the-council-is-organised/barnsleys-mps-and-meps 9. I would also like to request permission to re-publish the data provided in a publically accessible document/web-format. Barnsley CCG are happy to give their permission to re-publish the data provided. Fertility Policy.docx FOI 57 rc’d 06 May 2014 1) The number of referrals from GPs in your CCG under the government's Channel/PREVENT anti-terrorism scheme in the full year until March 2014 Barnsley CCG does not hold this information may I suggest you contact NHS England, South Yorkshire Police and GP Surgeries directly. 2) How many patients did this involve? 3) To which agency were these patients referred? 4) In deciding these referrals what potential signs of vulnerability and indicators have staff identified in patients that they thought showed a propensity to terrorismrelated activities? FoI No: 58 – received 7 May 2014 1. The Cardio Vascular Disease (CVD) Outcomes Strategy (published in April 2013) makes a number of recommendations in relation to the treatment and care of Atrial Fibrillation. a. Has your organisation (CCG) taken steps to implement the recommendations? i. If not, why not? b. Has your organisation (CCG) Barnsley CCG agreed a Local Enhanced Scheme (LES) for atrial fibrillation The scheme was drawn up in February 2013 and predates the Cardiovascular Disease Outcomes Strategy but covers the areas within the Strategy to the same standards.. This was supported by an educational event held for GPs. Public Health have been running campaigns to alert patients to the consequences of AF e.g. stroke as well as general health education. If not, why not? N/A communicated the implementation of the recommendations (as outlined in the Cardio Vascular Disease (CVD) Outcomes Strategy, strategy) to patients in your local area? i. If so, how? ii. If not, why not? 2. 3. 4. a. Has your organisation (CCG) communicated the implementation of the recommendations (as outlined in the Cardio Vascular Disease (CVD) Outcomes Strategy, strategy) to patients in your local area? i. If so, how? Answer as 1a) Answer as in 1a) ii. If not, why not? N/A 2. The CVD Outcomes Strategy states that patients with Atrial The CVD Outcomes Strategy states that Fibrillation are not always properly anti-coagulated; has your patients with Atrial Fibrillation are not always Clinical Commissioning Group taken steps to improve properly anti-coagulated; has your Clinical anticoagulation in Atrial Fibrillation patients? Commissioning Group taken steps to improve a. If so, what steps? anticoagulation in Atrial Fibrillation patients? a. If so, what steps? Barnsley has achieved a significant improvement against Quality and b. If not, why not? Outcomes Framework Atrial Fibrillation Targets and “Guidance of Risk Assessment and Stroke Prevention for Atrial Fibrillation” (GRASP-AF) The CVD Outcomes Strategy predicts that 18% electronic audit tool results due to the local enhanced scheme referred to in of those persons with Atrial Fibrillation are Q1a) response :undiagnosed, and states that there is a need for patents to be diagnosed earlier; have you The national “Guidance of Risk Assessment and Stroke Prevention for Atrial taken steps to achieve higher levels of, and Fibrillation” (GRASP-AF) electronic audit tool was run by the Primary Care earlier, diagnosis? Information Services (PRIMIS) team across all thirty eight Barnsley practices a. If so, what steps? in November and December of 2012. The tool found 1057 high-risk patients b. If not, why not? with a CHADS2 score of 2 or more (≥2) who were not taking anticoagulants. This identified a large unmet need in the management of Atrial Fibrillation and The draft NICE guideline on AF suggests that stroke prevention. the prescription of aspirin as a treatment for Atrial Fibrillation must be discouraged and A CCG Atrial Fibrillation Review Service was introduced in March 2013; this removed from all guidance. involved primary care clinicians undertaking a structured review of patients a. Is aspirin included in local guidance as a identified by the tool as having significant risk of stroke and the optimisation of treatment for Atrial Fibrillation? prophylactic anticoagulant therapy and evidence based interventions to b. Have you advised clinicians that aspirin is reduce their risk. 5. no longer a recommended anticoagulation The objectives of the service were as follows: treatment for AF? To undertake a structured stroke review on the 1057 patients identified with a CHADS2 score of 2 or more and complete an AF review In terms of treatment options for AF, proforma for each patient reviewed. alternatives to Aspirin and Warfarin include the To ensure that AF patients who were not receiving anticoagulant NICE-approved Novel Oral Anti-Coagulants therapy and at high risk of stroke are reviewed in the most appropriate (NOACs) Apixaban, Dabigatran and setting by the most appropriate clinician. Rivaroxaban. Do you operate internal guidance that supersedes NICE recommendations? If so, To ensure the delivery of a local, equitable, prompt, consistent and please provide details. high quality health care service. Practice level training sessions were delivered to practice clinicians prior to patient reviews’ taking place and the review work was completed in thirtyseven of the thirty-eight Barnsley practices by mid-September 2013. Primary care review work identified that a large proportion of patients were coded as having untreated AF using the GRASP –AF tool, where the AF had actually resolved, been misdiagnosed or miscoded (including CHADS2 score < 2) and this accounted for approximately one fifth (22.5%) of the original identified sample. Bleeding risk death, frailty, cognitive or functional decline and patient preference were issues in contraindication or non-concordance (declining) anticoagulant therapy and accounted for a further three fifths (57.9%) of the identified sample. Of the remaining fifth (19.5%) of eligible patients, 151/189 (80%) were successfully initiated on an oral anti-coagulant and only 6 /189 (0.6%) had not had a review by end of the agreed monitoring period and were followed up until all reviews had been completed. A Patient Experience Questionnaire was randomly sent to fifty seven (37.7%) patients who were started on an oral anticoagulant. Twenty nine questionnaires were returned and gave a very positive overall response , in that the majority of patients were very satisfied with reviews which had been undertaken, the information received and preferred being managed close to home by their GP practice b. If not, why not? N/A 3. The CVD Outcomes Strategy predicts that 18% of those persons with Atrial Fibrillation are undiagnosed, and states that there is a need for patents to be diagnosed earlier; have you taken steps to achieve higher levels of, and earlier, diagnosis? a. If so, what steps? The CCG have tried to standardise diagnostic equipment held by all GP practices across Barnsley. We have purchased blood pressure monitors that can detect AF and also ECG machines so that all practices have the same basic level of equipment. This means that if a healthcare assistant who may not be trained to detect AF via taking a pulse does a blood pressure they may incidentally detect AF during a health check as they would be alerted by the equipment and then the practice would be able to perform an ECG to confirm the diagnosis. If not, why not? N/A 4. The draft NICE guideline on AF suggests that the prescription of aspirin as a treatment for Atrial Fibrillation must be discouraged and removed from all guidance. a. Is aspirin included in local guidance as a treatment for Atrial Fibrillation? b. Have you advised clinicians that aspirin is no longer a recommended anticoagulation treatment for AF? I have attached a copy of resource materials which went as guidance to clinicians as part of training referred to in response to Q2, this was coupled with local training sessions as referred to in Q2. This complies with NICE guidance. 5. In terms of treatment options for AF, alternatives to Aspirin and Warfarin include the NICE-approved Novel Oral Anti-Coagulants (NOACs) Apixaban, Dabigatran and Rivaroxaban. Do you operate internal guidance that supersedes NICE recommendations? If so, please provide details. Answer as response Q4 FoI Request No: 59 – received 9 May 2014 1. Please provide the number of patient referrals funded by the CCG for access to health services from each named AQP provider for each service delivered via Any Qualified Provider in 2013/14 I would like the information arranged in a specific way, preferably in an Excel file. The patient numbers should be broken down first by AQP service, and then further by named provider. For example, audiology services may have been made available under AQP - in this case, patient numbers should be broken down by each named audiology AQP provider. To give a hypothetical example of how the information should be provided: AQP service: Audiology Providers: Specsavers - 238 referrals Easthampton NHS Hospital Trust - 106 referrals Old Oak Surgery - 86 referrals If any provider is registered under more than one AQP service, please provide their figures separately for each AQP service. This request is only for patients referred under AQP arrangements, not for patients referred to AQP providers for non-AQP services (e.g. "complex cases" referred to NHS providers outside AQP criteria). In terms of definitions, "the number of patient referrals funded by the CCG for access to health services" is simply how many patient referrals were made by the CCG to each provider under the AQP arrangements. Patients can choose which provider they are referred to. but this should still be considered a "referral" for the purposes of this request. I am assuming the information is recorded by referral numbers rather than individual patient numbers; if the reverse is true, then please provide the information for patient numbers, stating clearly that this is the case. "Funded by the CCG" simply means NHS patients. "Access to health services" again simply means to receive care or treatment from the provider under the AQP arrangements. FoI Request No: 60 – received 9 May 2014 Is If homeopathy a treatment or prescribed, offered and/or commissioned at your CCG? Please, reply by using Yes or No, and adding comments if necessary. homeopathy is a treatment prescribed and/or Is homeopathy a treatment or prescribed, offered and/or commissioned at your CCG? Please, reply by using Yes or No, and adding comments if necessary. NO If homeopathy is a treatment prescribed and/or commissioned at your CCG, please provide the total expenditure of the CCG over the last fiscal year (1 April 2013 – 31 March 2014). commissioned at your CCG, please provide the total expenditure of the CCG over the last fiscal year (1 April 2013 – 31 March 2014). If In In possible, also specify the conditions for which homeopathy has been prescribed and/or commissioned during that period, please. case homeopathy is provided through an external provider, please also specify the name of that organisation. case you hold data from before the formation of the CCGs in April 2013, I would also like to request: o The annual expenditure of the CCG on homeopathy over the fiscal years of: If possible, also specify the conditions for which homeopathy has been prescribed and/or commissioned during that period, please. In case homeopathy is provided through an external provider, please also specify the name of that organisation. In case you hold data from before the formation of the CCGs in April 2013, I would also like to request: o The annual expenditure of the CCG on homeopathy over the fiscal years of: 2010 – 2011 2011 – 2012 2012 – 2013 2010 – 2011 2011 – 2012 2012 – 2013 FoI Request No: 61 – received 14 May 2014 Could you please supply me with a record of each contract the above named CCG has awarded for the provision of health care services for the purposes of the NHS. In line with obligations under The National Health Service - refer to attached spreadsheet • a description of the health care services to be provided under the contract, - refer to attached spreadsheet • the total amount to be paid or, where the total amount is not known, the amounts payable to the provider under the contract, - This information is exempt in accordance with the Freedom of Information Act Section 43(2) Commercial interests, which states that information is exempt if its disclosure would prejudice, or would be likely to prejudice, the commercial interests of (Procurement, Patient Choice and Competition) Regulations 2013, please ensure that each of these records in particular, includes: the CCG or anyone else • the dates between which the contract provides for the services to be provided, and - refer to attached spreadsheet • the name of the provider awarded the contract and • a description of the process adopted for selecting the provider. the address of its registered office or principal place of Services are procured in accordance with the CCG’s Procurement Strategy ( business, see http://www.barnsleyccg.nhs.uk/strategies-policies-and-plans.htm on web • a description of the health care services to be site) and EU Procurement Law Competitive tendering is applied where provided under the contract, appropriate. • the total amount to be paid or, where the total amount is not known, the amounts payable to the provider under the contract, • the dates between which the contract provides for the services to be provided, and • a description of the process adopted for selecting the provider. In addition, could you please supply me with: • information about any services which the CCG are currently putting out for tender or expressions of interest; and • a list of all services which the CCG is planning or considering putting out for tender in the next 18 months? Please include in this information any provisional dates for the awarding of contracts and/or starting of new services. FoI No 62 – received 14 May 2014 FoI No 63 – received 15 May 2014 For each of the financial years 2011-12, 2012-13 and Barnsley CCG was established on 01/04/2013 and therefore can only provide the information from that date. 2013-14, please provide the following information: a) the total sum spent on translation and interpretation services by your trust a) the total sum spent on translation and interpretation services by your trust The budget for interpreting in 13-14 was £85,472, the expenditure was £106,781. b) the list of languages for which such services were obtained b) the list of languages for which such services were obtained c) for each of the languages listed in b) , the sum spent on translation and interpretation services for that language Polish Russian Mandarin Gujarati Thai Somali Portuguese an Slovaki Italian an British Sign Tamil Language Latvian Bengali Punjabi Albanian Lithuania n Mirpuri Amharic Greek Romani an Bulgari an Canton ese Japane se Urdu Hindi Farsi Turkish French Dari Kurdish (Bahdini) Korean Tigrinya Amharic Pashto Kurdish (Sorami) Lingala Hungaria n Arabic Swahili Vietnamese German FoI No 64 – received 15 May 2014 If you have ADHD service for Adults & Children either or both ? c) for each of the languages listed in b) , the sum spent on translation and interpretation services for that language The CCG is unable to split the sum spent into translation and interpretation services If you have ADHD service for Adults & Children either or both ? Adult ADHD service commenced in April 2013 1) The number of people diagnosed in your CCG area adults and children separately since diagnosis started? 1) The number of people diagnosed in your CCG area adults and children separately since diagnosis started? Number of referrals received for diagnosis for adult ADHD since commencement of service = 33 2) The total cost of diagnosis per person adult and child and the number of people diagnosed in the last year? 2) The total cost of diagnosis per person adult and child and the number of people diagnosed in the last year? Unit cost for adults not yet clearly established. 3) Please also inform me if you can on the number or people on medication for one year or more? 3) Please also inform me if you can on the number or people on medication for one year or more? FoI No: 65 – received 15 May 2014 For each of the last two years for which data is available Information not known by adult commissioner. Barnsley CCG have not spent any funding on pornography in the last 2 years. (ie broken down into an annual basis), please tell me how much NHS Barnsley CCG has spent on pornography. Please also supply me with a list of companies from which pornography has been procured, and levels of spending with each company. If possible, please break down this spending between printed material and video material. If possible, please also provide me with the names of any magazines or videos/DVDs that have been purchased. FOI 66 – rcd 19 May 2014 Copy of Copy of FOI Request from Luciana Berger MP (2).xlsx 1. Please fill in the table on the sheet labelled 'Question 1' (copied below for reference) to give us a historic picture of spending in your area over the last 6 years. If you do not have the data before or after a certain date, please fill in the table as far as your data allows, and note in your response the time range. 2. Please fill in the table on the sheet labelled 'Question 2' (copied below for reference). I am asking what were the actual and planned spending for your PCT/CCG on Improving Access to Psychological Therapies (IAPT) services in: a. 2012/13, b. 2013/14, and c. 2014/15. 3. Please fill in the table on the sheet labelled 'Question 3' (copied below for reference). I am asking what were the actual and planned savings for your PCT/CCG from secondary mental health services accruing from this additional investment in IAPT services in: a. 2012/13, b. 2013/14, and, c. 2014/15 FOI 67 - Rcd 19 May 2014 The CCG does not currently hold any information which identifies the spend on these categories over the requested time periods. I am currently conducting research with the objective of reducing purchase costs for CCG’s. The company that I am working for has applied for Drug Tariff Listing for a new category product that would fall into the following BNF Chapters and Sections: Stoma Appliances (23) Stoma Appliances (23) Adhesive Removers (Sprays/Liquids/W ipes) (15) Under the Freedom of Information Act please provide your annual spend in the above two categories for the last two complete financial years. FoI Request No: 68 – received 21 May 2014 I request the following information: 1) The number of patients currently receiving NHS The CCG would have to interrogate the NHSBA EPACT system to obtain this data. I must therefore refer this FOI to :emailing [email protected] or writing to Information Governance Compliance Team Health and Social Care Information Centre 1 Trevelyan Square Skin Fillers And Boar Lane Protectives (80) Leeds LS1 6AE The NHS Information Centre holds information showing the cost and volume of prescribing of these categories for Barnsley and all CCG’s and publishes sets of the drug chapter data periodically down to practice level on their website. Funded Nursing Care 2) The number that are currently overdue a review 3) The number of patients currently receiving NHS Continuing Health Care 4) The number currently overdue a review 5) The number of pending initial assessments for either FNC or CHC that have been pending for more than 28 days. FoI Request No: 69 – received 21 May 2014 1. Barnsley offer 2 cycles of IVF 2. Women intending to become pregnant must be between the ages of 18-42 years. No new cycle should start after the women's 43rd birthday. 3. The female patient's BMI should be between 19 and 30 prior to referral to tertiary services. Neither partner should have any living children (this includes adopted children but not fostered) from that or any previous relationship. IVF will not be funded for patients who have been sterilised or unsuccessfully undergone reversal of sterilisation. Cohabiting couples must have been in a stable relationship for a minimum of 2 years. 4. What is the average cost to the CCG per IVF/ICSI cycle ? Currently £2,868 5. How many IVF/ICSI cycles have Barnsley Patients undergone in each of the last five years ? 2009/10 2010/11 2011/12 21 cycles 40 20 2012/13 2013/14 13 24 6. In each of the last five years, how many of these were NHS Funded ? All of them. Fertility Policy 2014.docx FoI Request No: 70 – received 23 May 2014 This response relates only to those services that the CCG are newly commissioning during 2014/15. Please provide details of: Patient pathways / services being commissioned by the CCG for 2014/15 Patient pathways / services being commissioned by the CCG for 2015/16 Value / cost of each patient pathway / service being commissioned Method by which these patient pathways / services will be commissioned Our intention is to go out to an Any Qualified Provider (AQP) procurement for the following services during the first half of 2014/15: Carpal Tunnel Surgery Vasectomy ENT/Aural Care The advert for these will be posted on the Supply2Health website. The costs for these services have not yet been agreed. A number of other Business Cases are currently being discussed via our Programme Boards and some of these services may need procuring. The details of these have not yet been finalised or agreed. FOI request: 71 - received 23 May 2014 I would be grateful if you could let me know at your earliest convenience details about the treatments for men who experience erectile dysfunction as a result of prostate cancer treatment by completing the following I have completed the questionnaire on the attached email and it has been accepted. However it does not save the response it just appears to have sent it directly to Prostate Cancer UK – PAT FOSTER survey: http://prostatecanceruk.polldaddy.com/s/freedom-ofinformation-request-erectile-dysfunction-treatments FOI request: 72 - received 27 May 2014 In order to assist you with this request I am outlining my query as specifically as possible (please see attachment). The data requested relates to NHS Continuing Healthcare assessments, eligibility and funding. The information will be used in my Masters dissertation which I am currently undertaking at Cardiff University Law School. I am requesting information from Clinical Commissioning Groups in England and as such require the information electronically. If you are responsible for dealing with freedom of information requests for more than one Clinical Commissioning Group please could you complete another column on the spreadsheet attached. Completed response to FoI 72.xls attached doc.xls FoI request 73 - received 27 May 2014 This is a FOI request for information about applications for CHC funding made to your CCG. Attached is a form which is being sent to CCGs in England. I would be most grateful if you could complete and return it to me. FOI_Survey Table _Barnsley_150614 Completed.docx ATTACHMENT.docx FOI request 74 - received 30 May 2014 The CCG is not currently signed up to any rebate schemes for Pharmaceutical products. I would like to request information on any rebate schemes that the CCG is signed up to in regards to Pharmaceutical products. FoI Request 75 - received 30 May 2014 Which organisation or organisations were the TCS contracts were awarded to in your area? (This might be a local acute trust, a stand-alone community trust, a private provider, etc) What was the value of your CCG’s main community services contract in 2013-14? (If the exact value has not yet been calculated, the most recent estimate to the nearest £m will suffice.) When does your CCG plan to re-tender TCS services? Which organisation or organisations were the TCS contracts were awarded to in your area? (This might be a local acute trust, a stand-alone community trust, a private provider, etc) South West Yorkshire Partnership Foundation Trust (SWYPFT) What was the value of your CCG’s main community services contract in 2013-14? (If the exact value has not yet been calculated, the most recent estimate to the nearest £m will suffice.) £77,202,142.26 When does your CCG plan to re-tender TCS services No proposals to tender all services. Elements of this contract may be subject to procurement in the future as a result of pathway reviews and the CCG’s transformation plans. Have any services originally included in the local TCS contract since Have any services originally included in the local TCS been contracted separately? (For instance, in some areas TCS might contract since been contracted separately? (For originally have included dermatology or MSK services, but in some areas instance, in some areas TCS might originally have these have been tendered as individual services). NO included dermatology or MSK services, but in some areas these have been tendered as individual services).
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