120302 MSK Implementation Pack FINAL

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					Extension of Patient choice of Any
       Qualified Provider in
 Musculoskeletal (MSK) Services
     for Back and Neck Pain
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Preface

Introduction

This implementation pack has been designed to support commissioners to deliver Any
Qualified Provider (AQP) in Musculoskeletal (MSK) services for Back and Neck Pain
locally. It has been developed by NHS commissioners, clinical experts and DH officials,
working in partnership. The use of this pack is not mandatory. Commissioners can
refine it to meet local needs and, over time, help to improve it. The pack is simply a
place to start, avoiding duplicating effort.

This pack should be used for services that are commissioned using the Any Qualified
Provider (AQP) model – where commissioners are aiming to secure innovation or
deliver more choice for patients for example. Other forms of procurement are also
available, which might suit other circumstances, more details of these can be found in
DH procurement guidance.

The AQP impact assessment shows that the cost of procuring services per project
under AQP is lower than existing arrangements:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsLegis
lation/DH_128457

This pack has been prepared by working with a range of professionals, from both
clinical and commissioning backgrounds and we recommend that commissioners using
these packs continue to engage with clinicians, professionals and a wide range of
providers wherever possible.

Generally we expect there to be consistency across service specifications to sustain
quality and help to spread best practice, but where necessary specifications should be
amended to reflect local variations in need .

More information and further resources for commissioners can be found here:
http://nww.supply2health.nhs.uk/AQPRESOURCECENTRE/Pages/AQPHome.aspx,
including a pricing principles document that should be read alongside this
implementation pack.

If commissioners do come up with innovative new ways to drive up the quality of care by
offering choice of provider - please use the AQP resource forum to share your hard
work.

Workforce, education and training implications

When commissioning a service under patient choice of AQP, there are some important
workforce, education and training considerations, which commissioners must take into
consideration. Annex 2 provides some additional details on these issues.
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Public Sector Equality Duty

Commissioners should have regard to the Public Sector Equality Duty when
commissioning services for patients. Please refer to Annex 3: Public Sector Equality
Duty and visit the Department of Health website for more information on 'Equality and
Diversity'.

Glossary

A glossary of terms used within this implementation pack is included in Annex 4.

Next Steps

This pack may be used by commissioners undertaking AQP in MSK services for Back
and Neck Pain through 2012/13. An evaluation of the pack and the AQP process will be
undertaken during this period. In the meantime, if you have any questions or comments
on this pack, please contact AQP.Queries@dh.gsi.gov.uk
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Document Management

Document Control

Issue Date Version Distribution List                Contact Details




Document Approvals

This Document requires the following approvals.
Name             Signature         Title             Version   Date of Issue




Track Changes

Version   Date    Details of Changes included in Update                Author(s)
  No
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CONTENTS OF THIS PACK

Section 1
Section B –Service Specification ..................................................................................... 8

Section 2
Recommendations on the information requirements patients need to make an informed
choice ............................................................................................................................ 80

Section 3
Recommendations for Qualification ............................................................................... 86

Section 4
Commissioning Guidance .............................................................................................. 90

Annex 1
Acknowledgements ..................................................................................................... 117

Annex 2
Considerations............................................................................................................. 120

Annex 3
Public Sector Equality Duty ......................................................................................... 122

Annex 4
Glossary ...................................................................................................................... 124
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Forward
The 2010 health white paper ‘Equity and Excellence: Liberating the NHS’ and
supporting document ‘Liberating the NHS: Greater choice and control’ clearly signalled
the intention to provide greater choice for patients in most sections of healthcare. In July
2011, the Department of Health published ‘Operational Guidance to the NHS on
Extending Patient Choice of Provider’ setting out guidance regarding implementing ‘Any
Qualified Provider’ (AQP) including musculoskeletal (MSK) services for back and neck
pain as one of the initial service lines to be offered through AQP.

The goal is to enable patients to choose any qualified provider where this will result in
better care. Choice of provider is expected to drive up quality, empower patients and
enable innovation to support the delivery of Quality, Innovation, Productivity and
Prevention (QIPP). Importantly, extending choice of AQP provides a vehicle to improve
access, address gaps and inequalities and improve quality of services where patients
have identified variable quality in the past.

In July, the Department of Health (DH) published guidance to support the phased
expansion of Patient Choice of Any Qualified Provider to community and some mental
health services.

To support the NHS, volunteer PCT clusters1 were identified to work with emerging
CCGs and the DH to co-produce the development of an implementation pack for a
selection of services. The production of the pack was supported by DH and required the
cluster to work with patient groups (both locally and from service / patient representative
organisations), providers, regulatory bodies, clinical professionals and other interested
commissioners to prepare a pack that is tested and suitable for sharing for use by other
NHS commissioners.

The implementation pack for MSK services for Back and Neck pain has been developed
by NHS North West London with support from our buddy cluster for this work, NHS
South Central and in conjunction with a wider national reference group.

This service specification is intended to provide an example to commissioners who wish
to offer MSK services for back and neck pain via an Any Qualified Provider service, and
forms part of a wider implementation pack.

The implementation pack includes the following:
Section 1
Section B –Service Specification
Section 2
Recommendations on the information requirements patients need to make an informed
choice


1
    Lead PCT clusters/Clinical Commissioning Groups
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Section 3
Recommendations for Qualification
Section 4
Commissioning Guidance
Annex 1
Acknowledgements
Annex 2
Considerations
Annex 3
Public Sector Equality Duty
Annex 4
Glossary
           Section 1

Section B –Service Specification
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Section 1 INDEX

SECTION B PART 1 - SERVICE SPECIFICATION
B1_1.0   Population Needs .......................................................................................... 12

B1_2.0   Scope ............................................................................................................ 13

B1_3.0   Applicable Service Standards ....................................................................... 23

B1_4.0   Key Service Outcomes .................................................................................. 28

B1_5.0   Location of Provider Premises ...................................................................... 28

B1_6.0   Individual Service User Placement ................................................................ 28

SECTION B PART 2 - ESSENTIAL SERVICES

SECTION B PART 3 - INDICATIVE ACTIVITY PLAN
B3_1.0   Indicative Activity Plan................................................................................... 30

SECTION B PART 4 - ACTIVITY PLANNING ASSUMPTIONS
B4_1.0   Commissioning Ambitions based on Activity Plan ......................................... 31

B4_2.0   Capacity Review ........................................................................................... 32

B4_3.0   Prices and Payment ...................................................................................... 33

SECTION B PART 5 - ACTIVITY MANAGEMENT PLAN

SECTION B PART 6 - NON-TARIFF AND VARIATIONS TO TARIFF PRICES
B6_1.0   Non-Tariff Prices ........................................................................................... 36

B6_2.0   Variations to Tariff Prices .............................................................................. 36

SECTION B PART 7 - EXPECTED ANNUAL CONTRACT VALUES

SECTION B PART 8 - QUALITY
B8_1.0   Part 1 - Quality Requirements ....................................................................... 38

B8_2.0   Nationally Specified Events [DN: To be finalised] ......................................... 43

B8_3.0   Never Events ................................................................................................. 44
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SECTION B PART 9 - QUALITY INCENTIVE SCHEMES
B9_1.0        Part 1 - Nationally Mandated Incentive Schemes .......................................... 45

B9_2.0 Commissioning for Quality and Innovation (CQUIN) [DN: To be finalised
together with revised drafting]........................................................................................ 46

B9_3.0        Locally Agreed Incentive Schemes ............................................................... 55

SECTION B PART 10 - ELIMINATING MIXED SEX ACCOMMODATION PLAN

SECTION B PART 11 - SERVICE DEVELOPMENT AND IMPROVEMENT PLAN

SECTION B PART 12 - SERVICE USER, CARER AND STAFF SURVEYS
B12_1.0 Service User, Carer and Staff Surveys ......................................................... 58

SECTION B PART 13 - CLINICAL NETWORKS AND SCREENING PROGRAMMES

SECTION B PART 14 - REPORTING AND INFORMATION MANAGEMENT
B14_1.0 National Requirements Reported Centrally................................................... 60

B14_2.0 National Requirements Reported Locally...................................................... 61

B14_3.0 Local Requirements Reported Locally .......................................................... 62

B14_4.0 Data Quality Improvement Plan .................................................................... 63

SECTION 1 APPENDIX 1 – Currency Paper
S1A1.1        Our Aim ......................................................................................................... 65

S1A1.2        Context .......................................................................................................... 65

S1A1.3        Currency Development.................................................................................. 65

S1A1.4        Suggested Approach to Developing a Local Tariff ........................................ 70

S1A1.5        Data sources available to support setting a local tariff .................................. 77

TABLES

Table 1: Quality Requirements ...................................................................................... 38

Table 2: Nationally Specified events .............................................................................. 43

Table 3: National Definition (part of standard contract) ................................................. 44

Table 4: Summary of goals ............................................................................................ 47
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Table 5: Summary of indicators ..................................................................................... 47

Table 6: Detail of Indicator (to be completed for each indicator).................................... 48

Table 7: Milestones (only to be completed for indicators that contain in-year milestones)
...................................................................................................................................... 49

Table 8: Rules for partial achievement at final indicator period/date ............................. 49

Table 9: Outturn Value percentage for the relevant Contract Year ................................ 50

Table 10: Quality Incentive Payment ............................................................................. 50

Table 11: Service Development and Improvement Plan ................................................ 57

Table 12: Data Quality Improvement Plan ..................................................................... 63

Table 13: Potential currency models ............................................................................. 67

Table 14: Key factors affecting initial assessment ......................................................... 72

Table 15: Key factors affecting follow up treatments ..................................................... 73

Table 16: Key factors affecting other variable costs / non-pay ...................................... 73

Table 17: Key factors affecting other variable costs / non-pay ...................................... 74

Table 18: Approaches to accounting for this cohort of patients ..................................... 76

FIGURES

Figure 1: Process map 1 - Assessing patient suitability for AQP MSK service .............. 19

Figure 2: Process map 2 - AQP MSK service ................................................................ 20

Figure 3: Suggested process for determining appropriate tariff for AQP MSK services 71

Figure 4: MSK costing tool............................................................................................. 79
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SECTION B PART 1 - SERVICE SPECIFICATION

Mandatory headings 1 – 3. Mandatory but detail for local determination and agreement.

Optional headings 4 – 6. Optional to use, detail for local determination and agreement.

All subheadings for local determination and agreement.

Service Specification No.

Service                                   AQP Back and Neck Pain Musculoskeletal Treatment
                                          Service
Commissioner Lead

Provider Lead

Period                                    2012/13
Date of Review


This service specification forms part of the NHS Standard Contract Terms and
Conditions and must be read in conjunction with the same.

B1_1.0             Population Needs

B1_1.1             National/ local context and evidence base

In Europe nearly one-quarter of adults are affected by long-standing musculoskeletal
(MSK) problems that limit everyday activity1. In the UK 16.5 million people have back
pain2. In addition, 20% of the population present each year with a new onset or
recurrences of an MSK problem3.

Musculoskeletal disorders are the fifth highest area of spend in the NHS consuming
£4.2 billion in 2008/9 4 and increasing each year. MSK conditions also have a
significant social and economic impact, with up to 60% of people who are on long-term
sick leave citing MSK problems as the reason2 and patients with MSK forming the
second largest group (22%) receiving incapacity benefits5.




1 Department of Health, 2006. Musculoskeletal Services Framework
2 Clinical Standards Advisory Group for Back Pain. London, HMSO, 1994
3 Clarke A & Symmons D. The burden of rheumatic disease. Medicine 2006; 34 (9): 333-335
4 ARMA 2010. Liberating the NHS: Transparency in outcomes – a framework for the NHS
5 CBI in associate with AXA, 2005. ‘Who care wins: absence and labour turnover 2005’


                                                        Section 1                         Page 12
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Currently there are wide variations in the quality of service provision for the treatment of
MSK back and neck problems, with:

        Limited patient choice in some areas;
        Long waiting times to access the service;
        Lack of community based services; and
        Poor patient experience and outcomes.

[Local commissioners to insert local population needs data and drivers for
change]

B1_2.0              Scope

B1_2.1              Aims and objectives of service

The aim is to provide a comprehensive, patient-centred, easy to access back and neck
pain service in the community, which delivers high quality, efficient services in line with
national guidance and local requirements.

The service objectives are:

     To give patients a choice of provider.
     To provide improved access to services closer to home.
     To reduce waiting times to access the service and deliver treatment to enable
      patients to reach their individual treatment goals sooner. This could include an
      improved quality of life, return to work, more manageable pain.
     To deliver clinically effective treatments, that reduce the demand on secondary
      care services and reduce the need for more costly interventions.
     To provide community services that have a strong emphasis on patient education
      and self-management, thereby promoting active, healthy lifestyles and reducing
      recurrence of injury or illness.

B1_2.2              The Service

The service required is for the community based provision of assessment, treatment
and management of back and neck pain in line with the acceptance and exclusion
criteria and service requirements outlined in this specification.

The service requirements have been designed with consideration of NICE guidelines for
Low back pain: early management of persistent non-specific low back pain1; Map of
Medicine pathways for Low Back Pain – initial management2 and for neck pain1;

1
  Clinical guidelines CG88 Low back pain: Early management of persistent non-specific low back pain, 2009. National Institute for
Health and Clinical Excellence
2
  http://healthguides.mapofmedicine.com/choices/map/low_back_pain1.html



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Musculoskeletal Services Framework2; and built upon the learning from existing service
model studies3.

B1_2.3             Any acceptance and exclusion criteria

B1_2.3.1           Referral criteria:

A patient is eligible for referral to the service if they present with primarily back or neck
pain with or without ‘referred’ symptoms to the limbs including:

       Whiplash associated disorders
       Stiffness and restricted movement
       Cervicogenic headaches
       ‘Mechanical’ neck and back pain
       Degenerative pain
       Postural related neck and back pain.

B1_2.3.2           Referral Mechanisms:

‘Urgent’: Patient referral is considered urgent if one or more of the following apply:

       Patient dependent on strong analgesics e.g. tramadol.
       Severe sleep disturbance due to condition.
       Clinical condition likely to significantly and quickly deteriorate without intervention.
       Severe impairment of activities of daily living.
       Deteriorating neurological states.

‘Standard’: All patient referrals that are not categorised as urgent, for example:

       Patient with intermittent pain.
       Patient has a mild to moderate reduction in functional ability.
       Mild to moderate impairment of activities of daily living.
       Patient’s condition has the potential for improvement with intervention.

Exclusions: Patients who meet any the following conditions are not appropriate for
referral and therefore not covered in this service:

     Suspicions of serious pathology– urgent to secondary care or as per locally
      agreed pathways.
     Patients under 16 years of age
     Patients that do not meet referral criteria.

1 http://healthguides.mapofmedicine.com/choices/map/neck_pain1.html
2 Department of Health, 2006. Musculoskeletal Services Framework
3 Back and neck pain services case study: Manual Therapies Back & Neck Service, NHS North East Essex –
http://healthandcare.dh.gov.uk/back-and-neck-pain-services



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    Patients who are not registered with a GP in locality.
    Patients who it is recognised at point of referral / initial assessment have little or
     no potential for further or sustained improvement through undertaking a course
     treatment.
    Housebound patients
    Patients with widespread or chronic (greater than 1 year) musculoskeletal pain.
    Patients who have a primary peripheral limb problem with secondary back and
     neck pain (e.g. hip or shoulder problems, foot or gait abnormalities).
    Women who are over 35 weeks pregnant.

B1_2.4        Service description

The community based back and neck pain treatment service incorporates a package of
care including:

    An initial assessment;
    Follow up appointments as appropriate to clinical need; and
    Support to patients for self-care.

B1_2.4.1      Requirements at each stage of the care package

B1_2.4.1.1    Self-care

The provider must encourage patients to be more involved in their own care and
empower them to take further responsibility for wellness. The provider must provide
information to patients (and as appropriate their carers) regarding self-care, in
accordance with best practice. Providers must ensure that this is undertaken at the
outset and continued throughout the whole package of care and that a self-care
management plan is provided to the patient upon discharge from the service.

B1_2.4.1.2    Initial clinical assessment

Providers are required to undertake an initial assessment appointment for all patients.
During this appointment the provider must assess whether it is an appropriate referral
and that the patient would benefit from their treatment package. For accepted referrals,
it is expected that treatment should normally commence during this initial assessment
appointment and a patient management plan should be agreed.

This initial assessment must include the identification of any red flags (indicators in the
history or examination suggestive of serious underlying pathology) which should be
managed as per local pathway.

The initial assessment must also include the identification and any yellow flags
(indicators in the history or examination of psychosocial (surmountable) obstacles to



                                            Section 1                              Page 15
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recovery). All providers must be able to identify these obstacles and be able to work
with patients towards overcoming them.

For all accepted referrals a Patient Reported Outcome Measure (PROM) pre-treatment
questionnaire should be completed by the patient at the time of this initial assessment.

For all accepted referrals the provider should notify the GP and provide a copy of the
patient’s agreed intended care package.

If a referral is not accepted by the provider, the provider will return the referral
documentation to the referrer (GP or interface service) with detailed reasons for
rejection sufficient to minimise inappropriate referrals in the future, and make
recommendations (where appropriate) for on-going management of this patient.

[Dependent upon local circumstances this may be through an interface service which
holds responsibility for the triage of patients with more complex MSK conditions.]

B1_2.4.1.3          Follow-up appointments

For all referrals that are accepted, the provider will provide a package of care consisting
of the necessary treatment required to meet the individual clinical needs of the patient.

Providers will need to set out in their response document which treatments they will
provide. Any treatment offered as part of the package of care must have robust,
evaluated clinical evidence. Treatments may include, but not be limited to, the following:

        Manual therapy: joint mobilisations and manipulation;
        Soft tissue mobilisation: muscles, ligaments, cartilage, neural;
        Exercise programmes;
        Acupuncture.

It is anticipated that the treatment will consist of, on average 4 follow-up sessions,1
however the duration of treatment should be appropriate to clinical need, and therefore
where patients require more sessions this should be provided as part of the package.
Note that as NICE Guidelines for Non-Specific Low Back Pain2 state up to 9 sessions,
any patient who is deemed to require more than 9 sessions should be sent back to the
GP following the 9th session for determination of appropriate course of action. The
intervals between sessions should be consistent with good practice and appropriate for
individual patient needs.




1
  Please refer to the accompanying currency paper that includes further details regarding the decision to suggest an average based
on initial to follow up ratio of 1:4.
2
  Clinical guidelines CG88 Low back pain: Early management of persistent non-specific low back pain, 2009. National Institute for
Health and Clinical Excellence


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B1_2.4.1.4    Discharge from service

Patients should be discharged from the service when the desired clinical outcomes
have been reached and/or it is deemed that a patient could derive no further benefit
from continuing the course of treatment. Patients should be invited to complete the post-
treatment PROM questionnaire and patient experience questionnaire at this stage.

Upon discharge patients are to be provided with a written maintenance programme and
advice specific to their individual needs.

Within 5 working days of discharge from the service the provider will supply a discharge
summary to the patient, and their GP. Discharge summary will include:

      A copy of the written maintenance programme
      Details of treatment given
      Details of clinical outcomes
      Any additional recommendations, including the conditions for re-referral to the
       same or another service

It is a requirement of all providers to ensure that at the end of their NHS-funded
treatment patients are discharged promptly from the care of the provider and GPs are
informed. If a patient re-presents within a 1 year, with either the same problem or with a
different problem and requests a private consultation then the GP should be informed of
this, provided that the patient consents to this.

B1_2.4.1.5    Out of scope

All diagnostic tests are out of scope for this service. If diagnostic tests are required, the
provider must pass this request to the referring GP. It should be recognised that it is not
anticipated that diagnostic tests will be a common request.

Patient transport arrangements do not form part of this service specification. Patients
will be expected to make their own transport arrangements to the provider for treatment.
Those patients who are entitled to assistance with transport under existing NHS
arrangements will be able to access this and it will be organised by their GP / as per
local arrangements.

B1_2.4.1.6    Did Not Attend (DNA)

It is in the providers’ interest to ensure they have mechanisms in place to minimise the
number of patients who fail to attend pre-arrange appointments. If a patient DNAs an
appointment they should be offered on further appointment. Should the patient fail to
attend this appointment they may be discharged from the service at the provider’s
discretion. The patient should be sent a copy of their self-care management plan upon
discharge from service, and the GP sent a discharge letter.


                                          Section 1                                  Page 17
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B1_2.5       Care pathway

This specification is designed to capture the activity following decision to refer to the
back and neck pain service. [The care pathway will be as per local agreements, and
factors for consideration, will necessarily be specific to your locality].

The process flows (Figure 1 and Figure 2), below illustrate:

    Assessing patient suitability for AQP MSK Service
    Patient journey for AQP MSK Service




                                        Section 1                                Page 18
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  Process map 1: Assessing patient suitability for AQP MSK service
Figure 1: Process map 1 - Assessing patient suitability for AQP MSK service
       NWL Integrated Formulary: Project Charter
 Primary                                                                                                                                                Yes
                                                                                                                                                                    AQP process
 Care                                                                       Yes                                                                                       (map 2)
                                              Patient
                                                                                                                 Patient        Yes
                                           assessed by               Patient
                    Patient                                                             Patient under          suitable for            Self care     Follow-up
                                               GP as               meets AQP
                presents at GP                                                               16?                self care?                           required?
                                            requiring `             criteria?      No                   No
                                             follow-up
                                                                                                                No

                                                                                            Yes              Patient referred                                 No
                                                                                                               to interface                                           Discharge
                                                                                                               service (via
                  Referral criteria:                                                                         RMS if present)
                  Patient with primarily back or neck pain with or without ‘referred’
                  symptoms to the limbs e.g. whiplash associated disorders,
 Interface /      stiffness and restricted movement, headaches, mechanical low
                  back pain, degenerative pain, postural related neck and back
 RMS              pain.                                                                                                                 Patient
 services                                                                                                      Interface                                            AQP process
                                                                                                                                      meets AQP     Yes
                  Exclusions:                                                                                service triage                                           (map 2)
                                                                                                                                       criteria?
                  • Suspicions of serious pathology– urgent to secondary care or
                    as per locally agreed pathways
 Secondary        • Paediatrics (under 16 yrs)                                                                                            No
 Care             • Patients who are not registered with a GP in locality                                                                                             Trauma &
                  • Patients that have already received a course of treatment for                                                                                   orthopaedics
                    the same condition within 12 months.* If initial management
                                                                                                                                                     Patient
                    did not work or the patient has deteriorated then these patients
                    should be assessed in the interface service for clinical                                                                       referred as
                                                                                                                                                                   Rheumatology
                    governance reasons (e.g. missed underlying pathology).                                                                          per local
                  • Patients who it is recognised at point of referral / initial                                                                    protocols
                    assessment have little or no potential for further or sustained                                                                                  Pain mgmt.
                    improvement through undertaking a course treatment                                                                                                 service
                  • Housebound patients (note that if commissioners wish to
 Community          include housebound patients in scope then additional
                    consideration will be required regarding the professional                                                                                        Community
 Care setting       standards to ensure the necessary training has been                                                                                             physiotherapy
                    undertaken).
                  • Patients with widespread or chronic musculoskeletal pain are                                                                     Patient
                    out of scope.                                                                                                                  referred as     Community pain
                  • Patients who have a primary peripheral limb problem with                                                                        per local       mgmt. service
                    secondary back and neck pain are also out of scope (e.g. hip                                                                    protocols
                    or shoulder problems, foot or gait abnormalities).                                                                                             Other community
                                                                                                                                                                       services

 Paediatrics
                                                                                          Patient
                                                                                        referred as                                                                Paediatric care
                                                                                         per local                                                                    pathway
                                                                                         protocols



                                                                                            Section 1                                                                       Page 19
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 Process map 2: AQP MSK service
Figure 2: Process map 2 - AQP MSK service
       NWL Integrated Formulary: Project Charter
 Primary
 Care                                                                                                       No         GP
                                      Patient given     Patient
                Patient suitable                                          RMS service                                practice
                                       information    selection of                                                   booking
               for AQP (GP route)                                          in place?
                                      on providers     provider                                                      process

                                                                              Yes
 Interface /
 RMS                                                                                                                  RMS
 services                                                                                                            booking
                                                                                                                     process
                                                                              Yes

                                                                                                                       GP
               Patient suitable for   Patient given     Patient
                                                                         RMS service                                 practice
                 AQP (interface        information    selection of                                                   booking
                     service)         on providers     provider           in place?
                                                                                                            No       process


 AQP MSK                                                                                                                                       Follow-up treatments include:
 service                                                                                                                                       • Manual therapy




                                                                                        First appointment
                                                                                                                                               • Soft tissue mobilisation
                                                                                                                 Initial clinical              • Exercise programmes                   Discharged
                                                                                                                  assessment                   • Acupuncture




                                                                                                                                    Yes
                                                                                                                  Suitable for            Commence          Follow-up          Treatment
                                                                                                                  treatment?               treatment        treatment          complete


                                                                                                                   No

                                                                                                                                    No
                                                                                                                                           Referral                                  Patient sent back
                                                                                                                    Red flag?                                                            to referrer
                                                                 Red flag = suspicion                                                      rejected
                                                                 of serious pathology


 Secondary                                                                                                              Yes
 care
                                                                                                                    Patient
                                                                                                                  referred as                                                        Secondary care
                                                                                                                   per local                                                            services
                                                                                                                   protocols




                                                                              Section 1                                                                                                       Page 20
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B1_2.5.1      Referral source and route

It is recognised that self-care is important in ensuring healthy back and necks, and
where appropriate (non-urgent referrals) the referrer may choose to provide
conservative management (medication, advice, literature, re-assurance) for an
appropriate period of ‘watchful waiting’. Those patients whose conditions do not
respond to conservative management will then be considered for the back and neck
pain service.

If the GP or Interface Service believes that the patient meets the referral criteria for the
service, they will complete a referral form (as agreed locally). The GP or Interface
Service will also provide the patient with an information sheet (as agreed locally).

[Options depending on local arrangements]:

    Referral is passed to Referral Management Service (RMS) and patient instructed
     to contact the RMS, once they have chosen their preferred provider, and the
     RMS will arrange the initial appointment.
    Patient chooses their preferred provider and referral is sent from GP practice. GP
     practice makes the initial appointment. For referrals from the interface service,
     these should also go via the GP – although this is subject to local protocols and
     procedures.

The referral will be valid for one month and patients should be made aware that they
must make contact with their GP practice or RMS within this timescale for the referral to
be accepted. This information should be reinforced with inclusion on relevant patient
literature.

B1_2.6        Continual service improvement / innovation plan

There are key expectations of providers around continuous improvement, with the focus
that providers will engage their patients and review their services periodically to sustain
efficient, effective and high quality services. In particular:

Service Improvement:

    Providers are expected to review service provision in the light of recent research
     to ensure that they are providing the most effective package of care.
    Providers should also demonstrate how they have already developed and
     improved their services through innovation.
    Providers are required to participate in and support research undertaken across
     all of the areas covered by this service.

Patient engagement:

    The Provider will record and monitor levels of patient experience with the service
     and identify themes, trends and areas for improvement.


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    The Provider will supply the results of surveys in full along with action plans for
     service improvement based on the outcome of patient surveys to the
     Commissioner.
    Patient surveys will include questions around access, communication, quality and
     overall experience.
    The Provider will comply with the NHS duty to involve users and stakeholders,
     and to undertake patient involvement under sections 242 and 244 of the NHS Act
     2006, and subsequent involvement legislation.
    The Provider will ensure that arrangements are made to secure the involvement
     of service users in the planning and development of services and in any
     proposals for changes in the way services are provided and/or in decisions that
     affect the operation of services.

B1_2.7       Population covered

The Service will be sensitive to individual patient needs, including gender, age, culture,
and religious beliefs. Specifically the provider will offer a preferred gender of
professional where appropriate e.g. for religious or cultural reasons.

B1_2.8       Access

B1_2.8.1     Provider requirements around access:

    The venue must be suitable and easily accessible to patients with good public
     transport links
    The service shall offer appointments at a suitable time and in easily accessible
     buildings (not restricted to medical buildings) for patients including provision for
     people with disabilities
    Special consideration may need to be paid to the provision of the service to
     accommodate race, language, physical and learning disability requirements and
     for those in employment as far as reasonable practicality allows
    A risk and suitability assessment of the venue must be undertaken and sent to
     the commissioner.

B1_2.8.2     Language:

    The service will be available to all patients who are registered with a local GP. If a
     translator is required the provider will be able to arrange and coordinate this via
     the commissioner
    The provider must ensure that printed materials can be made available in a
     suitable language and format so as to be accessible to all patients.




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B1_2.9        Interdependencies with other services

B1_2.9.1      Whole system relationships:

To ensure a patient’s experience is a streamlined journey and a good experience the
provider must work collaboratively with the commissioner, primary care and secondary
care providers and the interface service to deliver services in an organised and
cohesive manner, and to reduce sequential waits between services. Where appropriate,
the provider must demonstrate effective links with other statutory providers and
voluntary sector organisations.

Providers are expected to cooperate and share information with others involved in a
patients care, treatment and support while having regard to the patients’ rights to
confidentiality.

Upon initial receipt of referral (as well as throughout the course of treatment) the
provider should contact the patient’s GP for information that is appropriate and relevant
to the referral and patient’s care within the back and neck pain service. Upon discharge
from the service the provider is required to supply a discharge summary to the patient’s
GP.

The patient information leaflet that all patients will be given at time of referral will state
that patients should inform their provider at the time of initial contact if they do not wish
for the provider to contact their GP; however it should be noted that there are
circumstances where the patient’s GP would be contacted without consent of the
patient, particularly where there are issues of patient safety.

B1_3.0        Applicable Service Standards

B1_3.1        Applicable national standards e.g. NICE, Royal College

Any and all treatments undertaken by providers as part of the service must be robust,
evidenced based, clinically effective treatments and the provider must be qualified and
registered to provide these treatments.

B1_3.1.1      Professional standards and codes of conduct

Providers must be registered with the regulatory body appropriate to their profession
and must adhere to the professional standards and codes of practice set out by that
body.

B1_3.1.1.1    Chiropractic

Regulating body:
General Chiropractic Council




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Standards:
    General Chiropractic Council Code of Practice and Standard of Proficiency
     (effective from 30 June 2010).
    Continuing Professional Development (CPD) Mandatory Requirements
     (September 2004).

B1_3.1.1.2   Osteopathy

Regulating body:
General Osteopathic Council

Standards:
    Code of Practice (May 2005)
    Standard 2000 – Standard of Proficiency (March 1999)
    Continuing Professional Development – Guidelines for Osteopaths

Note that this will be the new combined Osteopathic practice standards from September
2012.

B1_3.1.1.3   Physiotherapy

Regulating body:
Health Professions Council

Standards:

      Guidance of health and character (Jan 2010)
      Standards for the Good Character of Health Professionals
      Standards for the Health of Health Professionals
      Standards of Conduct, Performance and Ethics (July 2008)
      Standards of Proficiency (November 2007)
      Standards of Education and Training (September 2009)
      Your guide to our standards for continuing professional development (May 2008)

B1_3.1.2     Requirement relating to premises for activity

The providers must ensure that the premises used are safe and suitable for the delivery
of this service. The service must be provided in a geographically convenient, easily
accessible location which:

      Complies with health and safety legislation
      Has disability access
      Has appropriate waiting and treatment area
      Is appropriately furnished and equipped with necessary equipment
      Is of the highest level of cleanliness and hygiene
      Is easily accessible via public transport.


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B1_3.1.3     Complaints

The provider must:

    Have a formal complaints policy and procedures through which patients can raise
     issues with the service
    Endeavour to resolve any complaints directly with the patient, and only escalate
     to the commissioner if the complaint cannot be resolved directly
    Adhere to local commissioner policies and procedures regarding complaints,
     including the need to inform the commissioner of all complaints
    Respond to complaints in line with the NHS complaints procedure and the
     relevant statutory regulatory body.

B1_3.1.4     Marketing of services

The provider will undertake communication activity and marketing campaigns in order to
promote the NHS funded service. This will include producing marketing materials,
information and literature relating to the service. Both the Commissioner and the
Provider have the right to approve content of such materials. Materials may include
posters, information sheets or electronic media on accessing the service.

In relation to the NHS branding, marketing and promotion of services, the Provider will
comply with the terms and conditions of this contract (Clause 24).

B1_3.1.5     Safeguarding children and vulnerable adults

Providers must adhere to the terms and conditions of the contract (Clause 4A)

B1_3.2       Applicable local standards

This is intended as a non-exhaustive list. Clause [16] takes precedence

B1_3.2.1     Referral response times

The provider must demonstrate the ability to manage referrals in a timely fashion.

    ‘Urgent’ referrals should be offered an initial assessment appointment within 72
     hours from the date the referral is received (subject to patient choice).
    ‘Non – urgent’ referrals should be offered an initial assessment appointment
     within 10 working days from the referral is received (subject to patient choice).

Note that for monitoring purposes the date of referral is the date that the provider
receives the referral from either the referral management service or GP practice.




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B1_3.2.2      Integrated governance

The provider will demonstrate that there are clear organisation governance systems and
structures, with clear lines of accountability and responsibility. The provider will ensure
clinical and corporate governance processes are in place to include:

    Clinical governance lead
    Incident reporting
    Infection control
    SUI / PSI reporting and analysis
    Quality assurance
    Clear policies to manage risk and procedures to identify and remedy poor
     professional performance
    Evidence of peer and patient review and action taken

B1_3.2.3      Information technology and information governance

Providers must ensure that they are familiar with and comply with the NHS minimum
information technology standards, and ensure (and be able to demonstrate) that they
have the necessary systems and processes in place to comply with the NHS
information governance requirements.

Providers must be Choose & Book compliant, or working towards compliance. Initial
appointments must be directly or indirectly bookable through Choose & Book.

The Provider must ensure that the storage of medical records and information which is
relevant to treatment and on-going care is passed between all parties in accordance
with the Caldicott Principles and Data Protection Act (1998).

Providers should have an electronic patient administration and reporting system, meet
IGSOC requirements and must be able to provide all necessary returns, including the
Community Data Set, to the commissioner in the required format.

Providers must ensure that patient experience and PROM questionnaires are available
in hard copy. Providers may also choose to offer patients the option of completing
patient experience and PROM questionnaires electronically. The provider must ensure
that they have the necessary systems and processes in place to manage the
administration of patient experience and PROM questionnaires.

B1_3.2.4      Audits

The provider must notify the commissioner of the result of any audit undertaken by a
professional regulating body, or any other NHS commissioner.

The provider must allow the commissioner, or any individual or organisation acting on
the behalf of the commissioner to inspect the quality of service through observation of



                                         Section 1                                 Page 26
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service delivery, audit of patient records and data, audit of business processes and
records relating to the service contract and audit of staff records, as required.

B1_3.3       Workforce

The service provider must describe and demonstrate that they are qualified to provide
this service, and how they will assure commissioners of their competency to practice
both at the time of contract letting, and throughout the contract life.

As per the NHS contract terms and conditions, providers must regularly and
systematically review their professional practice in line with the professional standards
as set out by their regulating body and be able to demonstrate how they assure this
through regular review and/or appraisals. A report of any review or appraisal that takes
place, including recommendations and any requirements for retraining, should be
available to the commissioners upon request.

Each provider must encourage and allow for their staff to undertake Continued
Professional Development consistent with the requirements of their professional
regulator.

The provider must ensure that the following levels of supervision are provided to the
clinical staff team:

    Management supervision
    Clinical supervision
    Safeguarding supervision

The provider must include the following roles (these do not need to be undertaken by
different people):

    Service manager responsible for ensuring a high quality of clinical practice by all
     practitioners within the service, including necessary supervision of more
     inexperienced or junior staff and that all staff, including subcontractors, meet the
     requirements as set out in the service specification and the NHS Terms &
     Conditions
    Caldicott guardian responsible for ensuring compliance with all information
     governance requirements.




                                        Section 1                                Page 27
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B1_4.0        Key Service Outcomes

The provider is to deliver a quality service to patients comprising safe clinical practice,
clinical effectiveness and good patient experience. The service outcomes will be
dependent on the local objectives for the service, but in all cases due consideration
should be given to the mechanisms required to collect and analyse the data required to
monitor and act on the delivery of these outcomes. The service outcomes are:

    90% of patients for urgent referrals are offered an initial assessment appointment
     within 72 hours from receipt of referral
    90% of patients for a non – urgent referral are offered an initial assessment
     appointment within 10 working days from receipt of referral
    90% of patients sampled to have an individual care management plan (minimum
     sample size is 20% of all patients
    100% of patients to be asked to complete a validated PROMS before treatment
     and afterwards
    95% of patients sampled should report overall satisfaction with the service
    95% of patients from protected characteristic groups (PCGs) should report overall
     satisfaction with the service
    95% of all sampled GP referrers should report overall satisfaction with the service

B1_5.0        Location of Provider Premises

The Provider’s Premises are located at:
[Name and address of Provider’s Premises OR state “Not Applicable”]

Not applicable

B1_6.0        Individual Service User Placement

[Insert details including price where appropriate of Individual Service User Placement]

Not applicable for this service specification




                                          Section 1                                Page 28
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SECTION B PART 2 - ESSENTIAL SERVICES

[For local agreement]

Not applicable.




                                   Section 1    Page 29
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SECTION B PART 3 - INDICATIVE ACTIVITY PLAN

B3_1.0        Indicative Activity Plan

Indicative Activity Plan



By choosing to offer this service to Any Qualified Provider, the commissioner
offers no guarantee of activity volume for any provider. Patients will choose the
provider they wish to carry out their treatment and this patient choice will drive
activity levels.

Local commissioners may choose to populate this section with historical activity
data available from your local area to illustrate the anticipated demand across
all providers.




                                         Section 1                                   Page 30
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SECTION B PART 4 - ACTIVITY PLANNING ASSUMPTIONS

B4_1.0       Commissioning Ambitions based on Activity Plan

[State “Not Applicable” where appropriate OR where inserted, the Commissioning
Ambitions must not conflict with information in Service Specifications. The standard
template published alongside this contract is recommended]

This section is for local determination, however priority areas and principles may
include:

    Delivering service within the agreed financial envelope.
    Secondary care: it is an expectation of commissioners that this service will reduce
     the demand on secondary care.
    Achieve a greater level of understanding of activity through robust reporting to
     inform commissioning decisions taken in the future.
    Self-care: increased awareness of, and emphasis on, the importance of self-care,
     and patient ownership of their own wellness.
    GPs: clear engagement with GPs and wider system relationships, including
     prompt discharge summaries that are clear and informative.




                                       Section 1                                Page 31
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B4_2.0       Capacity Review

[Where relevant to the Service, relevant parts of the Activity Plan and Capacity Review
should be inserted here.]

Not applicable




                                       Section 1                                Page 32
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B4_3.0        Prices and Payment

The Commissioner will use the information included in the monthly data return to
calculate payment. Exact details regarding timescales are for local determination and
alignment with the relevant clause of the NHS contract.

B4_3.1.1      Pricing

B4_3.1.1.1    Package of care:

£TBC – as per local tariff

For patients that attend an initial assessment but are not accepted for further
treatment by the service, the commissioner will pay a percentage of tariff [see
accompanying currency paper].

£TBC – as per local tariff

Did Not Attend (DNA) and Unable To Attend (UTA):

No more than 10% of all patient appointments will be allowed to be a DNA. If a provider
operates with a level above this then a financial penalty will be incurred.

B4_3.1.1.2    Time of payment

As per local commissioning agreement.

Providers will be required to return their monthly data set by the n th of each month.
Subject to validation of this, payment will be made within x days.

Payment will be made for all initial assessments within that period, and for any
packages of care commenced within that period.

B4_3.1.2      Method of payment

As per local commissioning agreement.

B4_3.1.3      Terms of payment

As per local commissioning agreement

Providers will be paid monthly based on activity undertaken (initial assessments and
packages of care).

The commissioner will undertake reviews of the service to assess the quality and
compliance with the contracted terms and conditions. This will include analysis against
performance and quality outcomes.




                                        Section 1                               Page 33
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The results from these quarterly reviews will inform decisions regarding any appropriate
performance management measures.




                                        Section 1                                Page 34
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SECTION B PART 5 - ACTIVITY MANAGEMENT PLAN

[Insert/append Activity Management Plan]




                                      Section 1   Page 35
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SECTION B PART 6 - NON-TARIFF AND VARIATIONS TO TARIFF PRICES

B6_1.0       Non-Tariff Prices

[For local agreement]




B6_2.0       Variations to Tariff Prices

[For local agreement]




                                     Section 1            Page 36
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SECTION B PART 7 - EXPECTED ANNUAL CONTRACT VALUES

[To be inserted for each Commissioner where relevant to the Services OR state “Not
Applicable”]

Exact details regarding timescales are for local determination and alignment with clause
‘x’ of the NHS contract.




                                        Section 1                                Page 37
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SECTION B PART 8 - QUALITY

         [DN: to be finalised following publication of Operating Framework]

B8_1.0        Part 1 - Quality Requirements

Table 1: Quality Requirements
Performance Indicator / quality       Threshold          Method of           Consequence
Indicator   requirement                                  Measurement /       of breach
                                                         Frequency

Referral   Referrals processed        90%                Monthly data set    Financial
management within service                                report              penalty
and access specification
           requirements
            Urgent within 72
             hours
            Standard within 10
             working days
Efficient      DNA rate to not        10% of total       Monthly data set    Financial
management exceed more than           patient            report              penalty
of the service 10% of all referrals   appointments
Efficient      Timely delivery of     100%               Receipt of data     Financial
management community data set /                          set returns on      penalty
of the service any other required                        time
               data return monthly
Clinical      Number of appropriate -                    SUS data and
effectiveness (relevant to back and                      audit of patient
              neck pain) referrals to                    journeys
              the interface service
              and secondary care
Self-      Patient has signed         90% of sample      Audit
management copy of individual         audited.           Patient
           management plan            Minimum            experience
           with self-care advice      sample to be at    questionnaire
           included                   least 20% of all   (include specific
                                      patients.          question)




                                        Section 1                                   Page 38
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Performance Indicator / quality      Threshold           Method of            Consequence
Indicator   requirement                                  Measurement /        of breach
                                                         Frequency

Clinical      Agreed and validated 100% of               Monthly data set Financial
effectiveness Patient Reported     patients to be        report             penalty
              Outcomes Measure     asked to              Quarterly analysis
                                   complete a            return
                                   PROM pre and          Audit
                                   post treatment
Patient       Standardised patient   95% of patients     Patient
experience    experience             sampled should      experience
              questionnaire (hard    report overall      questionnaire.
              copy or electronic     satisfaction with   Quarterly and
              dependent on patient   the service.        accumulative
              preference) to be      Minimum             annual report to
              issued at discharge    sample to be at     include an
              points.                least 20% of all    analysis of
                                     patients.           completed user
                                                         questionnaires
                                                         demonstrating %
                                                         of those satisfied
                                                         or very satisfied
                                                         with service.
Information   Patient records and   95% compliance Monthly data set
sharing       associated                           reports
              letters/reports                      GP survey
              completed and sent to
              GP within 5 working
              days of initial
              assessment and
              follow-up




                                       Section 1                                   Page 39
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Performance Indicator / quality       Threshold            Method of            Consequence
Indicator   requirement                                    Measurement /        of breach
                                                           Frequency

Peer           A consistent GP          95% satisfaction   Quarterly and
satisfaction   satisfaction survey will rate               accumulative
of service     be designed and sent                        annual report to
               to all referring GP’s.                      include an
               95% of GPs sampled                          analysis of
               should report overall                       completed GP
               satisfaction with                           questionnaires,
               service                                     demonstrating %
                                                           of those satisfied
                                                           or very satisfied
                                                           with service.
Patients are   Professional           -                    Audit
treated by     registration and
registered,    evidence of clinical
competent      governance
clinicians
whose
practice is
regularly
reviewed
Service     Patient experience   100%                      Annual report to
improvement questionnaires and                             demonstrate
            peer satisfaction                              recommendations
            surveys to capture                             and actions taken
            areas for                                      to address areas
            improvements. 100%                             of service
            of recommendations                             improvement
            made and agreed with
            Commissioners are
            addressed




                                          Section 1                                  Page 40
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Performance Indicator / quality      Threshold           Method of             Consequence
Indicator   requirement                                  Measurement /         of breach
                                                         Frequency

Patients      Safe and appropriate -                     Audit
treated in a environment that
safe and      meets the necessary
appropriate professional
environment standards according
that meets    to NHS T&Cs and
the           their own professional
necessary     body.
professional
standards
according to
NHS T&Cs
and their own
professional
body.




Reducing       Patient                95% satisfaction   Annual service
Inequalities   questionnaire          rate               user consultation
               should report overall                     questionnaire
               satisfaction rate from                    analysis,
               all protected                             specifying overall
               characteristic groups                     satisfaction levels
               (PCGs)                                    for PCGs
Reducing       An integrated patient 100%                Provider provides
Barriers       pathway, which                            demonstrable
               facilitates signposting                   evidence of %
               to wider                                  patients who
               communication/social                      receive
               support services                          information about
               (where appropriate)                       these support
                                                         services
SUIs, PSIs     In line with local   -                    In line with local
and            commissioners policy                      commissioners
complaints                                               policy




                                        Section 1                                   Page 41
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Patient Reported Outcome Measures (PROMs)

[Please see the accompanying guidance document for further information and
discussion regarding the use of PROMs for an AQP MSK service. The information
below is as suggestion only]

Providers should use the Bournemouth Questionnaire both pre-treatment and post-
treatment. Providers should also use the Global Perceived Effect scale post-treatment.

The Commissioner will provide template pre-treatment and post-treatment PROM
questionnaires.




                                       Section 1                               Page 42
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B8_2.0       Nationally Specified Events [DN: To be finalised]

Table 2: Nationally Specified events
Technical Nationally Specified   Threshold         Method of     Consequence
Guidance Event                                     Measurement   per breach
Reference




Not applicable




                                       Section 1                       Page 43
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B8_3.0         Never Events

Table 3: National Definition (part of standard contract)
Never Events            Threshold      Method of           Never Event
                                       Measurement         Consequence (per
                                                           occurrence)




Not applicable




                                      Section 1                          Page 44
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SECTION B PART 9 - QUALITY INCENTIVE SCHEMES

B9_1.0       Part 1 - Nationally Mandated Incentive Schemes

[For national determination]




                                   Section 1                  Page 45
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B9_2.0      Commissioning for Quality and Innovation (CQUIN) [DN: To be
finalised together with revised drafting]

Table 1: CQUIN Scheme

[The Parties are recommended to use the on-line standard template for CQUIN
schemes 2011/12 available on the website of the NHS Institute for Innovation and
Improvement (at
 http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html) to
facilitate the completion and recording of their CQUIN scheme.

Where the Parties use the on-line standard template, a copy of the completed scheme
must still be printed and appended to this Schedule 18 Part 2 in place of the tables
below.]

Quality Incentive Payments can be agreed to be paid monthly or by single annual
payments.

PLEASE DELETE AS APPROPRIATE “The Parties agree that Quality Incentive
Payments shall be paid monthly and therefore the provisions set out in paragraphs 5 to
13 below shall apply.” OR “The Parties agree that Quality Incentive Payments shall be
paid annually and therefore the provisions set out in paragraphs 14 to 19 below shall
apply.




                                       Section 1                               Page 46
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Table 4: Summary of goals1
Goal   Goal Name                     Description of               Goal             Expected        Quality Domain
Number                               Goal                         weighting        financial       (Safety,
                                                                  (% of            value of        Effectiveness,
                                                                  CQUIN            Goal (£)        Patient Experience
                                                                  scheme                           or Innovation)
                                                                  available)

1                                    [insert locally
                                     agreed goals]
2                                    [insert locally
                                     agreed goals]
3                                    [insert locally
                                     agreed goals]
4                                    [insert locally
                                     agreed goals]
etc                                  [insert locally
                                     agreed goals]
                                     Totals:

Table 5: Summary of indicators
Goal              Indicator          Indicator Name                             Indicator         Expected
Number            Number2                                                       Weighting         financial value
                                                                                (% of     CQUIN of Indicator (£)
                                                                                scheme available)

1                                    [insert the indicator or
                                     indicators that are agreed
                                     in respect of each goal]
2
3
Etc
                                     Totals:



1 The on-line standard template on the website of the NHS Institute for Innovation and Improvement contains some additional fields
to assist its automated functions. Parties may include these additional fields in the completed version of the scheme included in the
contract
2 There may be several indicators for each goal


                                                            Section 1                                                      Page 47
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Table 6: Detail of Indicator (to be completed for each indicator)
Indicator number
Indicator name
Indicator weighting (% of CQUIN scheme
available)
Description of indicator
Numerator
Denominator
Rationale for inclusion
Data source
Frequency of data collection
Organisation responsible for data collection
Frequency of reporting to commissioner
Baseline period/date
Baseline value
Final indicator period/date (on which
payment is based)
Final indicator value (payment threshold)
Rules for calculation of payment due at
final indicator period/date (including
evidence to be supplied to commissioner)
Final indicator reporting date
Are there rules for any agreed in-year
milestones that result in payment?
Are there any rules for partial achievement
of the indicator at the final indicator
period/date?




                                         Section 1                  Page 48
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Table 7: Milestones (only to be completed for indicators that contain in-year
milestones)
Date/period milestone relates   Rules for achievement of     Date         Milestone
to                              milestones (including        milestone to weighting (%
                                evidence to be supplied to   be reported of CQUIN
                                commissioner)                             scheme
                                                                          available)




                                                             Total:

Table 8: Rules for partial achievement at final indicator period/date
(only complete if the indicator has rules for partial achievement at final indicator
period/date)
Final indicator value for the part achievement % of CQUIN scheme available for
threshold                                      meeting final indicator value




1.    Subject to paragraph 2, if the Provider satisfies a Quality Incentive Scheme
      Indicator set out in Schedule 18 Part 2 Table 1, a Quality Incentive Payment shall
      be payable by the Commissioners to the Provider in accordance with this
      Schedule 18 Part 2.

2.    The Commissioners shall not be liable to make Quality Incentive Payments under
      this Schedule 18 Part 2 to the Provider in respect of any Contract Year which in
      aggregate exceed the applicable Actual Outturn Value percentage for the
      relevant Contract Year set out below:




                                       Section 1                                 Page 49
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Table 9: Outturn Value percentage for the relevant Contract Year
Contract Year               Maximum aggregate Quality Incentive Payment

1st Contract Year           [For national determination and local insertion]




      and for the avoidance of doubt this paragraph shall limit only those Quality
      Incentive Payments made under this Schedule 18 Part 2, and shall not limit any
      Quality Incentive Payments made under any Quality Incentive Scheme set out in
      Schedule 18 Part 1 or Schedule 18 Part 3.

3.    The Provider shall in accordance with clause [33] of this Agreement submit to the
      Co-ordinating Commissioner a Service Quality Performance Report which shall
      include details of the Provider’s performance against and progress towards the
      Quality Incentive Scheme Indicators set out in Schedule 18 Part 2 Table 1 in the
      month to which the Service Quality Performance Report relates.

4.    The provisions set out in paragraphs 5 to 13 below apply in respect of Quality
      Incentive Payments made by monthly instalments. The provisions set out in
      paragraphs 14 to 19 apply in respect of Quality Incentive Payments made by a
      single annual payment.

      Monthly Quality Incentive Payments

5.    Where the Co-ordinating Commissioner and the Provider have agreed that
      Quality Incentive Payments should be made on a monthly basis by any
      Commissioners, then in each month after the Service Commencement Date
      during the term of this Agreement each relevant Commissioner shall make the
      default Quality Incentive Payment set out below to the Provider:

Table 10: Quality Incentive Payment
Commissioners               Monthly Quality Incentive Payment – 1st Contract Year

[insert name of each
Commissioner making
monthly CQUIN payments]




                                       Section 1                                Page 50
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and the Provider and the Co-ordinating Commissioner may from time to time, whether
as a result of a review performed under paragraph 6 below or otherwise, agree to vary
the default monthly Quality Incentive Payment for any Commissioner set out above.

6.    The Co-ordinating Commissioner shall review the Quality Incentive Payments
      made by the Commissioners under paragraph 5 on the basis of the information
      submitted by the Provider under this Agreement on the Provider’s performance
      against the Quality Incentive Scheme Indicators. Such reviews shall be carried
      out as part of each Review under clause [8].

7.    In performing the review under paragraph 6 the Co-ordinating Commissioner
      shall reconcile the Quality Incentive Payments made by the relevant
      Commissioners under paragraph 5 against the Quality Incentive Payments that
      those Commissioners are liable to pay under paragraph 1 on the basis of the
      Provider’s performance against the Quality Incentive Scheme Indicators, as
      evidenced by the information submitted by the Provider under this Agreement.

8.    Following such reconciliation, where applicable, the Provider shall invoice the
      relevant Commissioners separately for any reconciliation Quality Incentive
      Payments.

9.    Within [10] Operational Days of completion of the review under paragraph 6, the
      Co-ordinating Commissioner shall submit a Quality Incentive Payment
      reconciliation account to the Provider.

10.   In each reconciliation account prepared under paragraph 9 the Co-ordinating
      Commissioner:

      10.1    shall identify the Quality Incentive Payments to which the Provider is
              entitled, on the basis of the Provider’s performance against the Quality
              Incentive Scheme Indicators set out in Schedule 18 Part 2 Table 1 in
              those months of the relevant Contract Year that have elapsed at the time
              of the review;

      10.2    shall ensure that the Quality Incentive Payments made to the Provider in
              respect of completed Contract Years comply with the requirements of
              paragraph 2;

      10.3    may correct the conclusions of any previous reconciliation account,
              whether relating to the Contract Year under review or to any previous
              Contract Year; and

      10.4    shall identify any reconciliation payments due from the Provider to any
              Commissioner, or from any Commissioner to the Provider.



                                      Section 1                                Page 51
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11.   Within [5] Operational Days of receipt of the Quality Incentive Payment
      reconciliation account from the Co-ordinating Commissioner, the Provider shall
      either agree, or, acting in good faith, contest such reconciliation account.

12.   The Provider’s agreement of the Quality Incentive Payment reconciliation
      account (such agreement not to be unreasonably withheld) shall trigger a
      reconciliation payment by the relevant Commissioner(s) to the Provider, or by the
      Provider to the relevant Commissioner(s), as appropriate, and such payment
      shall be made within [10] Operational Days of the Provider’s agreement of the
      reconciliation account and the Provider’s invoice.

13.   If the Provider, acting in good faith, contests the Co-ordinating Commissioner’s
      Quality Incentive Payment reconciliation account:

      13.1    the Provider shall within [5] Operational Days notify the Co-ordinating
              Commissioner, setting out reasonable detail of the reasons for contesting
              such account, and in particular identifying which elements are contested
              and which are not contested;

      13.2    any uncontested payment identified in the Quality Incentive Payment
              reconciliation account shall be paid in accordance with paragraph 12 by
              the Party from whom it is due; and

      13.3    if the matter has not been resolved within 20 Operational Days of the
              date of notification under paragraph 13.1, either Party may refer the
              matter to dispute resolution under clause [28] (Dispute Resolution),

      and within [20] Operational Days of the resolution of any Dispute referred to
      dispute resolution in accordance with this paragraph 13 the relevant Party shall
      pay any amount agreed or determined to be payable.

      Single annual payment of Quality Incentive Payments

14.   Where the Provider and Co-ordinating Commissioner have agreed that one
      single Quality Incentive Payment should be made to the Provider by any
      Commissioner at the end of each Contract Year, then at the end of each Contract
      Year during the term of this Agreement each Commissioner set out in the table in
      this paragraph 14 shall, subject to the Provider’s performance against the Quality
      Incentive Scheme Indicators, make a single Quality Incentive Payment to the
      Provider in accordance with the procedure set out in paragraphs 15 to 19 below.




                                       Section 1                                Page 52
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc



      Commissioners making single annual Quality Incentive Payment at the end of
      the Contract Year

      [insert name of any Commissioner making a single annual CQUIN payments]

      [Insert amount of the single annual CQUIN payment for each relevant
      Commissioner]




15.   The Co-ordinating Commissioner shall, within [10] Operational Days of the end of
      the Contract Year to which the Quality Incentive Payments relate or its receipt of
      final information from the Provider on its performance against the Quality
      Incentive Scheme Indicators during that Contract Year (whichever is the later),
      submit to the Provider a statement of the Quality Incentive Payments to which
      the Provider is entitled on the basis of the Provider’s performance against the
      Quality Incentive Scheme Indicators during the relevant Contract Year, as
      evidenced by the information submitted by the Provider under this Agreement.

16.   Within [5] Operational Days of receipt of the Quality Incentive Payment statement
      from the Co-ordinating Commissioner under paragraph 15, the Provider shall
      either agree, or, acting in good faith, contest such statement.

17.   The Provider’s agreement of the Quality Incentive Payment statement (such
      agreement not to be unreasonably withheld) shall trigger a payment by the
      relevant Commissioner(s) to the Provider, and such payment shall be made
      within [10] Operational Days of the Provider’s agreement of the statement and
      the Provider’s invoice.

18.   In the event that the Quality Incentive Payment under paragraph 17 is paid
      before the final reconciliation account for the relevant Contract Year is agreed
      under clause [7] (Prices and Payment) of this Agreement, then if the Actual
      Outturn Value for the relevant Contract Year is not the same as the expected
      Annual Contract Value against which the Quality Incentive Payment was
      calculated, the Co-ordinating Commissioner shall within [10] Operational Days of
      the agreement of the final reconciliation account under clause [7] send the
      Provider a reconciliation statement reconciling the Quality Incentive Payment
      against what it would have been had it been calculated against the Actual
      Outturn Value, and a reconciliation payment in accordance with that
      reconciliation statement shall be made by the relevant Commissioner to the
      Provider or by the Provider to the relevant Commissioner, as appropriate, within
                                       Section 1                                Page 53
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      [10] Operational Days of the submission to the Provider of the reconciliation
      statement under this paragraph 18.

19.   If the Provider, acting in good faith, contests the Co-ordinating Commissioner’s
      Quality Incentive Payment statement under paragraph 15 or reconciliation
      statement under paragraph 18:

      19.1   the Provider shall within [5] Operational Days notify the Co-ordinating
             Commissioner, setting out reasonable detail of the reasons for contesting
             the relevant statement, and in particular identifying which elements are
             contested and which are not contested;

      19.2   any uncontested payment identified in the relevant statement shall be
             paid in accordance with paragraph 17 by the relevant Commissioner or
             the Provider, as the case may be; and

      19.3   if the matter has not been resolved within 20 Operational Days of the
             date of notification under paragraph 19.1, either Party may refer the
             matter to dispute resolution under clause [28] (Dispute Resolution),

      and within [20] Operational Days of the resolution of any Dispute referred to
      dispute resolution in accordance with this paragraph 19 the relevant Party shall
      pay any amount agreed or determined to be payable.




                                      Section 1                                Page 54
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


B9_3.0       Locally Agreed Incentive Schemes

[For local agreement]




                                   Section 1    Page 55
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


SECTION B PART 10 - ELIMINATING MIXED SEX ACCOMMODATION PLAN

                           [Insert/append EMSA Plan]



Not applicable




                                   Section 1            Page 56
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SECTION B PART 11 - SERVICE DEVELOPMENT AND IMPROVEMENT PLAN

Table 11: Service Development and Improvement Plan
Description of Scheme         Milestones                    Timescales                    Expected Benefit              Consequence of
                                                                                                                        Achievement/ Breach

[insert as defined locally]   [insert as defined locally]   [insert as defined locally]   [insert as defined locally]   Subject to clause [32]
                                                                                                                        (Contract Management)




Could include things that are applicable across the service e.g. access.




                                                                      Section 1                                                           Page 57
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SECTION B PART 12 - SERVICE USER, CARER AND STAFF SURVEYS

B12_1.0      Service User, Carer and Staff Surveys

[Mandatory but for local agreement – set out survey type, frequency, how it is to
be reported and publication method where relevant]

B12_1.1      Patient experience questionnaire

The provider will invite all patients to complete a patient satisfaction survey on
discharge from the service, with no less than 20% to be completed. Providers must
ensure that patient experience questionnaires are available as a hard copy; however
they may also choose to provide patients the option of completing electronically.

The commissioner will provide a template patient experience questionnaire to be used
across the service.

All returned patient satisfaction surveys will be analysed and evaluated by the provider.
The findings will be reported to the commissioner. Original copies should be retained
and made available to the commissioner if requested.

The commissioner, and GPs, may choose to undertake ‘spot-check’ patient satisfaction
surveys, or patient forum meetings as part of their approach to ensuring high quality
service delivery for patients and on-going performance management.




                                        Section 1                                 Page 58
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SECTION B PART 13 - CLINICAL NETWORKS AND SCREENING
PROGRAMMES

[For local agreement and not to conflict with any information in Service Specifications]




                                         Section 1                                 Page 59
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SECTION B PART 14 - REPORTING AND INFORMATION MANAGEMENT

[DN: Entire Section Under Review]

All information gathered for the purposes of reporting is subject to the requirements set
out in clause [27], (Data Protection, Freedom of Information and Transparency) and
clause [56] (Compliance with the Law).

B14_1.0      National Requirements Reported Centrally

1.    The Provider and Commissioner shall comply with the reporting requirements of
      SUS and UNIFY2. This includes compliance with the required format, schedules
      for delivery of data and definitions as set out in the Information Centre guidance
      and all Information Standards Notices (ISNs), where applicable to the service
      being provided.

2.    The Provider shall ensure that each dataset that it provides under this Agreement
      contains the Organisation Data Service (ODS) code for the relevant
      Commissioner, and where the Commissioner to which a dataset relates is a
      Specialised Commissioning Group, or for the purposes of this Agreement hosts,
      represents or acts on behalf of a Specialised Commissioning Group, the Provider
      shall ensure that the dataset contains the ODS code for such Specialised
      Commissioning Group.

3.    The Provider shall collect and report to the Commissioner on the patient-reported
      outcomes measures (PROMS) in accordance with applicable Guidance.

4.    The Provider shall comply with the national reporting requirements in relation to
      Sleeping Accommodation Breaches as set out in the Professional Letter.

[DN: This is not relevant to the nature of this service.]




                                        Section 1                                Page 60
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B14_2.0      National Requirements Reported Locally

As per 2012/2013 standard contract requirements.

Reports required by contract including activity report, quality performance, complaints
monitoring, report against service delivery improvement.




                                       Section 1                                Page 61
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc




B14_3.0       Local Requirements Reported Locally

[Insert information that is local required and agreed - to include format, method of
delivery and Frequency.]

Where relevant the provider will be required, each month, to return a completed national
data set for that month. It is expected that this will be in the form of the national
community information data set. Further information on this will be advised by the
Department of Health, and as this is subject to finalisation a template is not provided at
this stage.

This monthly data return should include:

    Patient information data
    Referral data – including whether it is ‘Non - urgent’ or ‘urgent’, date received,
     and if it was accepted or rejected
    Appointment & treatment data, including DNA and UTA
    Patient discharge data; including date discharge summary sent to GP
    Complaints data –including details of any investigation / resolution of complaints
    Details of whether the following have been provided to patient/ GP referrers (note
     that the analysis of these will not be returned monthly):
     o Patient reported outcomes pre-questionnaire or post-questionnaire as
        appropriate
     o Patient experience questionnaire
     o GP referral satisfaction questionnaire

B14_3.1       Patient Reported Outcome Measures (PROMs)

[Please see the accompanying guidance document for further information and
discussion regarding the use of PROMs and analysis of PROMs for an AQP MSK
service.]

Analysis of the PROMs and patient experience questionnaires will be undertaken by the
provider, and this analysis will be returned to the commissioner on a quarterly basis.

The provider should ensure that all originals are retained as the commissioner retains
the right to request original copies as part of the audit process.

B14_3.2       Reporting of SUIs, PSIs and complaints

As per local policies and protocols.




                                        Section 1                                 Page 62
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B14_4.0        Data Quality Improvement Plan

Table 12: Data Quality Improvement Plan
Data Quality      Data Quality      Method of         Milestone Date    Consequence
Indicator         Threshold         Measurement

[for local        [for local        [for local        [for local        [for local
definition]       definition]       definition]       definition]       definition]



Optional – can agree a data quality improvement plan at any point during the contract




                                        Section 1                                Page 63
        SECTION 1 APPENDIX 1 – CURRENCY PAPER

Back and Neck Pain Musculoskeletal Treatment Service
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


SECTION 1 APPENDIX 1 – CURRENCY PAPER

S1A1.1        Our Aim

This paper has been developed to inform commissioners and providers on the types of
currency and price that could be used locally to set up MSK community services.

A price/cost has not been provided, as per the AQP Implementation pack guidance,
price/cost is to be set locally. It is suggested that local commissioners set the same
price/cost for all providers of that service – therefore providers compete on quality by
using innovation. Commissioners will need to consider the application of a market forces
factor for some regions to cover increased costs of provision (e.g. central London). This
is explained further in Section 4.

This paper includes:

      Context;
      Currency Development;
      Setting Costs; and
      Suggested approach to developing a local tariff.

S1A1.2        Context

Historically block contracts have been used to commission MSK community Services.
Currently there is no national dataset in place to capture information which would allow
the analysis of

    The cost of MSK community services
    The scope for these MSK community services
    The activity levels for MSK community services

Through discussions with the Department of Health PbR Development Team it has been
agreed that at this stage it would not be possible to set a national tariff for MSK
community services in the English NHS.

S1A1.3        Currency Development

The term currency refers to the units of healthcare for which a payment is made and can
take a variety of forms. Currency is different from cost or price. A currency is the unit of
healthcare that will be paid for. The four principles of a good currency are:




                                         Section 1                                  Page 65
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The currency must be clinically meaningful – that is as a grouping of patients/service
users it is accepted by clinicians. Involvement of clinicians in designing the currency
packages will help ensure that they are clinically meaningful.

    The currency should have as much resource homogeneity as possible (“iso-
     resource”) – that is individuals within a proposed currency group should require a
     similar type and amount of resource. Considering the variables of patient need
     (and resource usage) will help you to define iso-resource.
    The currency should incentivise the provision of improved care. The group will
     have to consider the incentives and the outcomes that they developed for MSK
     patients. The group will have to be mindful of creating perverse incentives.
    The currency should be workable – this means that they should be supported by
     underlying information flows (available or attainable). The cost-benefit of
     granularity should be considered and data burdens should be kept to the minimum
     necessary for ease of implementation.

The MSK AQP Implementation Pack Core Team considered three currencies models for
the package of care that will be needed to treat patients. These are:

    Episodic
    Package of care
    Block contract

The table below captures the main discussion points that were considered when
determining the most appropriate currency for this service.

S1A1.3.1     Potential currency models

See Table 13 below for details.




                                       Section 1                                Page 66
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Table 13: Potential currency models
Currency Description               Benefits        Risks                    Mitigations                                  Note
type

Episodic   Fee per attendance Payment is only      Could incentivise        Add a requirement for any patients who       (x) would need to
           - many private     made for activity    provider to continue     need (>x) appointments, to be referred       be defined locally.
           providers use this delivered.           care beyond a point      back to their GP for re-referral if
           currency.                               where 'significant'      appropriate. However, this adds to           See Section
                                                   clinical benefit is      workload of GPs and inconvenience for        S1A1.3.3
           It is often                             added; always            patients.                                    regarding clinical
           appropriate to                          providing x                                                           and activity
           differentiate                           appointments.          Include a tiered payment system e.g.           evidence for
           between the                                                    paying a marginal rate for appointments        appropriate
           cost/time of initial                    Focus on inputs rather delivered after the initial x appointments,    number of
           appointment and                         than outcomes.         up to an agreed amount.                        treatment
           that of the follow up                                                                                         sessions
           appointments for                                                 Ensure framework for high quality care
           patients.                                                        exists alongside the currency
Package    Payment for a           Minimises       Could incentivise        By splitting the initial assessment from In order to set a
of care    package of care         incentive to    increased referral                                                local tariff an
                                                                            overall package of care you reduce risk of
           that delivers an        provide 'max'   rejection (paid full     inappropriate referral rejection, howeveraverage number
           agreed outcome.         number of       package whether you      introduce risk of inappropriate referral of treatment
           This would              treatments      provide any treatment)   acceptance.                              sessions will need
           incorporate initial                                                                                       to be agreed. See
           assessment and          Can allow for   Could introduce risk of By ensuring robust monitoring of provider Section S1A1.3.3
           follow up               more accurate   inappropriate early     performance (Clinical effectiveness       regarding clinical
           appointments as         financial       discharge.              measures including PROMS, ratio of        and activity
           required to meet        forecasting                             initial: follow up).                      evidence for


                                                                Section 1                                                            Page 67
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Currency Description              Benefits           Risks                     Mitigations                                 Note
type

           that outcome.                             Outcomes in MSK                                                        appropriate
                                                     services for back and     Risks around referral accept / reject can number of
                                                     neck pain are difficult   be mitigated by introducing a stratification treatment
                                                     to define and agree.      tool such as STarT Back, and/or GP           sessions.
                                                                               education to ensure higher quality
                                                                               referrals
Block      Lump sum over a               Any Qualified Provider does not guarantee any minimum activity levels,
contract   period of time, with                     therefore block contract currency is not applicable
           guaranteed activity
           levels




                                                                  Section 1                                                               Page 68
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


S1A1.3.2            Agreed currency

Through discussions with existing services in place and with the DH PbR team we
agreed a package of care currency model.

The service is for a package of care including:

     Support to patients for self-care;
     An initial assessment;
     Follow up appointments appropriate to clinical need.

The currency has been established based on an average of 5 sessions; initial clinical
assessment plus on average 4 follow up appointments (see Section S1A1.3.3 for
justification). It is expected that patients will receive the treatment that they require
appropriate to clinical need and in the instances when this is above the average patients
should still be treated within package of care. Note that as NICE Guidelines for Non-
Specific Low Back Pain1 state up to 9 sessions, any patient who is deemed to require
more than 9 sessions should be sent back to the GP for determination of appropriate
course of action.

In developing this service specification, and in particular in determining the currency to
use, consideration has been given to the potential financial risk from providing care to
patients with back and neck pain via an AQP service model. It is recognised that each
potential currency option has benefits and risks, and experience from other localities that
have implemented MSK services for back and neck pain suggests that it may be
necessary to review the currency model (and tariff) and amend once the service has
been ‘in-life’ for a period of months/years.

S1A1.3.3            Clinical evidence base to support suggested currency

The implementation pack team recognise that there is not a clinical evidence base
available to support decisions regarding an appropriate average number of treatment
sessions to deliver optimal outcomes for patients presenting to this service.

As such, to develop a suggested currency model the group has considered the relevant
NICE guidelines, activity levels from different services across the country and the findings
from the North East Essex PCT AWP back and neck pain service that has been running
for 3 years.

     NICE clinical guidelines suggest up to 9 sessions for non-specific low back pain
      (the most appropriate available for this service).




1
 Clinical guidelines CG88 Low back pain: Early management of persistent non-specific low back pain, 2009. National Institute for
Health and Clinical Excellence




                                                            Section 1                                                     Page 69
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     Activity levels reported by reference group and benchmarking data suggest a wide
      range of average number of treatment sessions1.
     The North East Essex AWP service for back and neck pain has amended the
      currency over the course of the service.
      o Episodic in year 1, up to 6 treatment sessions (before returning to GP to
           authorise more). Financial constraints contributed to decision to amend.
      o Episodic in year 2, up to 4 treatment sessions (before returning to GP to
           authorise more). Anecdotal concern from providers regarding outcomes
           contributed to decision to amend.
      o Package of care in year 3, based on an average of 1 initial plus 4 follow-up
           appointments (total 5), but with no requirement to return to GP to provide more
           than 5 treatments as if required, these should be delivered as part of the
           package for that patient.
       It should be noted that full analysis of the service has been undertaken on year
       one only, however analysis of years 2 and 3 (including outcome data) is currently
       being completed and this should be available in due course.
     The Chartered Society of Physiotherapy have advised that across all MSK
      conditions (not just back and neck pain) the mean nationally is 1:3.412.

It must be noted that the implementation pack team are aware of the limitations of these
data, including that:

     Different payment models incentivise different behaviour and this may influence
      the number of treatments provided
     Data sources may include MSK conditions wider than just back and neck pain
     The scope of services reported may be different

It is recommend that further work is undertaken in this area to develop a clinical evidence
base to inform future decisions around appropriate currency for MSK services for back
and neck pain.

As this is a new service, it is strongly recommended that commissioners carefully monitor
activity and outcome data for the service, and consider amending the currency model
(estimated average) and local tariff to ensure it remains appropriate and ensures
sustainability of service throughout the duration of the contract.

S1A1.4              Suggested Approach to Developing a Local Tariff

In developing a local tariff, commissioners should consider the following key areas, as
outlined in Figure 3 below:



1
  North West Alliance of Chief Operating Officers. ‘Benchmarking MSK Therapies Report’. July 2011, version 3.0. Available on
request from Benchmark Management Consulting Limited. Please contact Claire Holditch, Cholditch@nhs.net.
2
  The Chartered Society of Physiotherapy. ‘A Survey of NHS Physiotherapy Waiting Times and Musculoskeletal Workload and
Caseload in England.’ 2009-2010 Report. Avaiable on request via enquiries@csp.org.uk




                                                            Section 1                                                    Page 70
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Figure 3: Suggested process for determining appropriate tariff for AQP MSK services
1
    Key inputs prior to tariff                                                                               Suggested Process for determining
    modelling
                                                                                                             appropriate tariff for AQP MSK services
           Expected package duration (#
                      appts)
                                                            8                                            8                                   8
           Service scope, e.g. inclusion of                      Possible package tariff                     Possible package tariff              Possible package tariff
         transport, inclusion of diagnostics,                     modifier if referral is                    modifier if patient does             modifier reflecting the
          whether a see& treat approach is
          expected, whether translation is
                                                                rejected following initial                   not complete course of                delivery of desirable
                      in scope …                                       assessment                            treatment (DNA/ UTA)                       outcomes




                                      2                                            3                                        5                                     6                      7
                                           Initial assessment                          Follow up                                Fixed costs/                          Cost adjustments       Profit &
                                                                                       treatments                               overheads                             (if applicable)        contingency
                                                                                                                                                                                                                        8
                                                   Clinical time for                            Clinical time for                                                             MFF              Expected profit margin
                                                                                                                                     Facilities/ estates
                                                     assessment                                    treatment                                                                                                                   Single
                                                                                                                                                                                                                             package
                                                     Diagnostics                                                                             IT                                                     Contingency
                                                                                              Number of treatments                                                                                                             tariff
            Referral
                                                     Clinical time for
                                                                                                                                                                                                                               which
                                                                                                                                   Non-clinical staffing &
                                                treatment (if operating                                                               administration
                                                                                                                                                                                                                            reflects all
                                                  a see & treat model)                                                                                                                                                       elements
                                                                                                                                    Clinical governance
                                                                                                                                                                                                                              of cost
     8
          Package tariff
                                                                                                                                  Informatics/ Reporting
          not triggered if
             referral is
           rejected prior
              to initial               4
            assessment                     Other variable costs (non-pay)
                                                    Consumables associated with assessment & treatment

                                                                          Patient transport

                                                                       Translation services

                                                                       Capture of PROMS




                                                                                                                                Section 1                                                                                     Page 71
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Points 1 - 8 below refer to the stages as illustrated in Figure 3 above.

1. Key inputs prior to tariff modelling

Prior to the commencement of tariff modelling, it is necessary to determine key
components of the specification. Key factors affecting cost modelling include the
following:

      Assumed number of follow-up treatments per patient
      Inclusion of diagnostics
      Inclusion of related services (transport, translation, home visits)
      Specific requirements around performance reporting

2. Initial assessment

Key factors affecting cost include the following:

Table 14: Key factors affecting initial assessment
Factor                Considerations                         Guidance

Clinical time for      Duration of appointments           Is the same level of skill/
assessment             Expected efficiency – downtime seniority required to assess
                        between assessments                patients as is required to
                       Level of clinical skill/ seniority conduct follow-up treatments?
                        required, and associated cost
                                                             Note specification requirement
                                                             that red and yellow flags
                                                             should be detected at the point
                                                             of assessment

                                                             Is the same duration required
                                                             as for follow-up treatments?
Diagnostics           Which, if any, diagnostic tests?       Note that the reference service
                      Who provides diagnostic tests -        specification indicates that
                      order from defined list with known     diagnostic tests are out of
                      costs, or freedom to source            scope for the service
                      elsewhere / provide yourself e.g.
                      Chiropractic x-ray
Clinical time for     One possibility is that the initial   The reference specification
treatment (if         appointment should also include an assumes a see & treat model,
operating a see &     element of treatment. If this is the as part of which some element
treat operating       case for your specification, consider of treatment commences as
model)                whether the initial appointment       part of the initial assessment.
                      should be longer than subsequent


                                           Section 1                                 Page 72
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc



Factor                Considerations                          Guidance

                      follow-ups.


All staff costs should include on-costs, as accounted for locally.

3. Follow up treatments

Table 15: Key factors affecting follow up treatments
Factor                Considerations                          Guidance

Clinical time for      Duration of appointments           There are no cross-disciplinary
treatment              Expected efficiency – downtime standards around appointment
                        between assessments                duration; a range of examples
                       Level of clinical skill/ seniority is given within Section S1A1.5.
                        required, and associated cost

                      Is the same level of skill/ seniority
                      required to assess patients as is
                      required to conduct follow-up
                      treatments?

                      Is the same duration required as
                      assessments?
Number of          See section S1A1.3.2.                      Note that there are a range of
treatment episodes                                            possibilities, but the currency
/ follow-ups                                                  has been defined on the basis
                                                              of an average of four follow-
                                                              ups.


4. Other variable costs/ non-pay

These are costs which are associated with the delivery of care, and as such, scale broadly in
proportion with the number of patients treated by the service.

Table 16: Key factors affecting other variable costs / non-pay
Factor                Considerations                          Guidance

Consumables           Any consumables associated with         In general, clinical
associated with       treatment, e.g. acupuncture             consumables are unlikely to be
assessment &          needles                                 a major determinant of cost,
treatment                                                     but this should be verified


                                           Section 1                                  Page 73
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Factor                Considerations                         Guidance

                                                             locally
Patient transport     Only to be considered if they are      Note that the reference service
&translation          included within the local              specification indicates that
services              specification                          these features are out of scope
Capture of PROMs Depending on the frequency with             One of the desirable features
                 which a provider is expected to             of a PROM survey is that it can
                 sample PROMs, it may be                     be completed unaided; on this
                 necessary to devote clinical time at        basis this component of cost
                 the end of an episode of care to            may be assumed to be
                 supporting patient in populating a          negligible (depending on local
                 PROMS survey.                               requirements)
5. Fixed costs/ overheads

Table 17: Key factors affecting other variable costs / non-pay
Factor                Considerations                         Guidance

Facilities/ estates   As per local and national              For determination in
                      accounting conventions                 conjunction with local providers
IT                    Providers must meet the terms of
                      the NHS contract, which includes
                      requirements around information
                      governance.

                      The cost model should therefore
                      include consideration of the cost of
                      (for example) a robust PAS,
                      compliance with Choose & Book
                      etc.

                      Note that these capabilities could
                      be purchased outright and
                      amortised, lease for a market rate,
                      or (in the case of Choose & Book
                      integration) potentially delivered
                      from elsewhere within the MSK
                      pathway, e.g. through a referral
                      management service
Non-clinical          This might include:
staffing and           Reception and booking services
administration


                                         Section 1                                   Page 74
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc



Factor                Considerations                            Guidance

                       Service     management,            if
                        appropriate
Clinical              The cost model should include time
governance            for senior clinical input to ensure
                      clinical governance
Informatics/          Analysis of PROMs by provider
reporting             Monthly data set return,
                      quarterly/bi-annual PROM data
                      returns


6. Cost adjustments (if applicable)

If your tariff financial model is based on costs sourced from local services, then there
may be no requirement to adjust the figures to determine a ‘true’ cost.

If, however, costs have been sourced from alternative sources (e.g. national reference
costs), then it may be necessary to apply an adjustment to reflect the local market.
Where national costs have been used, it is appropriate to apply the Market Forces Factor
(MFF) which applies to your borough.

7. Profit & contingency

The tariff calculation should include provision for profit and contingencies.

The actual cost of providing the service per patient will vary with the number of patients
treated, since the fixed costs/ overheads must be apportioned across the total referral
volume.

Since the greatest unknown factor for a provider under AQP is the volume of patients
which will be referred, the cost model should be tested under a range of scenarios,
including a lower activity threshold at which a provider might break even.

8. Tariff modifiers

Note that, although the tariff price reflects a single package of care, there may be a need
to apply a number of modifiers to the price actually paid. These include:

Payment of a percentage of tariff rate if, following an initial assessment appointment, the
referral is rejected.

At the point of assessment, it will be identified that some patients are unsuitable for
clinical care in the service that they have chosen to attend. Rather than assuming that all
patients proceed to treatment, the tariff rate might include an adjustment to reflect this.


                                          Section 1                                Page 75
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


There are two possible approaches to accounting for this cohort of patients:

Table 18: Approaches to accounting for this cohort of patients
Approach       Description                     Benefits         Issues
No modifier Determine an expected              Simplicity of    May incentivise early
for rejected ‘rejection rate’ for all AQP      administration   discharge of patients
referrals    MSK services, and blend this                       Has the effect of
             into the tariff model. The                         reducing the headline
             effect of doing this will be that                  tariff rate, and hence may
             the tariff rate for a package of                   result in a smaller uptake
             care will be reduced, since                        amongst potential
             some patients will attract the                     providers
             tariff but will not receive
             treatment.
Introduce a    Patients to attract a reduced Addresses          Relative additional
modifier for   tariff if the referral does not perverse         complexity of
patients       proceed to follow-up care       incentives       administration
rejected at    following the initial
the point of   assessment. The size of the
assessment     tariff might be based on the
               actual cost of delivering the
               assessment, not including any
               follow-up care.


A tariff modifier if the patient DNAs/ UTAs

Fundamentally, the AQP MSK specification and currency model are outcome driven –
that is to say, payment is contingent on the delivery of healthcare outcomes following
completed packages of care, rather than the delivery of a specific number of
appointments. However, where the patient does not receive a completed package of
care, it follows that they are unlikely to have received the full clinical benefit of that
package, and hence there is merit in incentivising providers to manage down the
proportion of DNAs and UTAs.

DNA and UTA rates are, to a certain extent, a product of local factors beyond the direct
control of providers. With this in mind, the extent to which providers should be expected
to assume the risk of DNAs and UTAs is for local determination.

A practical way of implementing an equitable approach to the risk of DNAs/ UTAs might
be, for example:

    Each provider is required to measure and report on the proportion of patients who
     DNA/ UTA (including patients who DNA/ UTA their initial assessment appointment)



                                         Section 1                                    Page 76
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


    A KPI threshold for this measure should be set locally. Providers performing at, or
     above, the expected level should receive the full payment based on the local
     pathway tariff agreed
    Any DNA/ UTAs beyond the threshold should attract a financial penalty, to be
     subtracted from the total payment due to the provider for any given accounting
     period
    The size of the penalty is for local determination, but might be set as being broadly
     equivalent to the marginal cost of the missed appointment. In effect, once a
     certain threshold DNA/ UTA rate had been reached, providers will not be paid for
     any further DNA/ UTAs.

A tariff modifier to reflect the quality of outcomes in the service

There is a risk that linking payment to quality outcomes too early can lead to restriction of
the outcomes that providers are willing to report on. Also with no consensus on agreed
outcome measures for this field it adds to the complexity of implementation.

With this in mind, it is recommended that in the initial years of this service, it may be
prudent to avoid weighting the tariff paid according to the delivery of quality outcomes.

It may be that introducing a weighting of percentage of the tariff according to delivery of
quality can be introduced in later years of the service once quality measures, and the
regular and appropriate reporting of these, are established and embedded locally.

S1A1.5        Data sources available to support setting a local tariff

When determining a local tariff, commissioners can draw on three main data sources to
inform this work:

    NHS national reference costs
    NHS local reference costs from existing providers
    Local private sector reference costs

S1A1.5.1      Reference Costs 2009/10

As per the PbR guidance 2011-12, the collection of reference costs is supported each
year by detailed guidance and the NHS costing manual, designed to eliminate variation
caused by different methodologies. Reference costs are submitted on full absorption
basis, which simply means that all the running costs of providing these services are
included within the return. Each reported unit cost therefore includes:

    direct costs - which can be easily identified with particular activity (eg. consultants
     and nurses)
    indirect costs - which cannot be directly attributed to an activity but can usually be
     shared among a number of activities



                                          Section 1                                  Page 77
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


    overheads - which relate to the overall running of the organisation (eg. finance
     and human resources).

Reference costs 2009/10 for Community Physiotherapy are available (Figure 4 below)
looking at the unit costs for Physiotherapy Total Attendances - Adult (19 and Over) Non-
Consultant Led, Single Professional, Face to Face. The reference costs are shown in
two versions:

    Option 1, costs based on National, Lower Quartile and Upper Quartile unit costs.
     The totals reflect the total cost for one initial assessment and then four follow up
     appointments.
    For Option 2, given that as a general principle it is accepted that 75% of cost of
     running a service are attributed to staffing costs, we have used the same
     methodology to arrive at the total costs.

S1A1.5.2      Private Providers

We strongly recommend that commissioners undertake local market analysis of their
private providers.

From conducting a word search on the internet for ‘costs and MSK services’, the
following observations have been made:

      Initial assessments are on average more expensive than follow up appointments.
      Initial assessments are on average longer in duration that follow up appointments.
      The range in costs for initial assessment is from £30-95
      The range in length of initial assessment is 20 minutes to one hour.
      The range in follow up appointments is from £27-95
      The length in follow up appointments is from 20 to 45 minutes with the average 30
       minutes.

When undertaking local market analysis, commissioners should be aware of the variation
in the scope of services provided that may affect the cost and duration of appointments of
different providers.

S1A1.5.3      Local NHS Costs

Working with your local NHS provider(s) of community MSK services can help
development of an appropriate local tariff. The ease and accuracy of this will be
dependent on the data available from your local provider(s).

Where possible you should endeavour to access local data at a level that can inform the
cost headings as outlined in section 4, and use these to build your local tariff.




                                        Section 1                                 Page 78
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Figure 4: MSK costing tool
MSK costing tool

         1. Costs from 2009-10 reference cost schedules
                                                                   INITIAL APPOINTMENT                                                    FOLLOW UP APPOINTMENT

                                                                                            650A - Physiotherapy Total Attendances - Adult (19 and Over)                   Total
         Non-Consultant Led, Single Professional , Face to Face                                                                  £49                                £35            £189
                                                                                                                                     1                                4



                                                                                            650A - Physiotherapy Total Attendances - Adult (19 and Over)                   Total
         Non-Consultant Led, Single Professional , Face to Face                                                                  £36                                £26            £140
                                                                                                                                     1                                4



                                                                                            650A - Physiotherapy Total Attendances - Adult (19 and Over)                   Total
         Non-Consultant Led, Single Professional , Face to Face                                                                                                     £39            £212
                                                                                                                                      1                               4



         2. 75% of Costs 2009-10 reference costs (Approx just staffing costs)
                                                                    INITIAL APPOINTMENT                                                   FOLLOW UP APPOINTMENT

                                                                       650A - Physiotherapy Total Attendances - Adult (19 and Over)                                        Total
         Non-Consultant Led, Single Professional , Face to Face                                                                £36.75                             £26.25           £142
                                                                                                                                    1                                  4



                                                                       650A - Physiotherapy Total Attendances - Adult (19 and Over)                                        Total
         Non-Consultant Led, Single Professional , Face to Face                                                                    £27                            £19.50           £105
                                                                                                                                     1                                 4



                                                                       650A - Physiotherapy Total Attendances - Adult (19 and Over)                                        Total
         Non-Consultant Led, Single Professional , Face to Face                                                                                                     £29            £158
                                                                                                                                      1                               4

         http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123458.xls



                                                                                      Section 1                                                                            Page 79
           Section 2

    Recommendations on the
information requirements patients
 need to make an informed choice
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc



Section 2 INDEX

S2.1   Key content and distribution ............................................................................. 82
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Section 2 – Recommendations on the information requirements
patients need to make an informed choice
This guidance has been distilled from a range of sources, including existing community
musculoskeletal services, looking at best practice tools around patient information
engagement with local LINks and the members of the North West London Patient and
Public Advisory Group.

The key principles that underpinned the work in defining this guidance and
recommendations for commissioners, is that:

    Information will be provided in easy to understand, plain English style
    Information requirements is focused on the point of the pathway where patients
     have presented with a back and neck pain condition and been assessed as
     requiring treatment
    Any information developed and provided needs to be patient-centred and take
     into account patient s’ needs and expectations in order to empower patients
    There will be an overarching principle of providing open access to information
     about services, treatment and performance of providers as available
    Information provided should be comprehensive and easily accessible via different
     mechanisms, and made available in different formats as required.

S2.1      Key content and distribution
There are four key stages that have been identified where the availability of patient
information is helpful to ensuring that patients are kept informed about their progress
along an Any Qualified Provider pathway for back and neck pain services. These are:

Table 19: Key stages to aid informing patients of progress
Stage:                       Purpose:                     Source:

Information requirements To help patients understand From referrers (GP/ interface
at the point of referral their treatment options and service)
                         how to proceed to choosing
                         a provider and treatment
Starting treatment under     To help patients understand From referrers (GP/ interface
AQP                          what they should expect at service)
                             each stage of the pathway
Provider-specific patient    To help patients understand AQP Providers
information                  the treatment they are
                             receiving once it
                             commences




                                        Section 2                               Page 82
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc



Stage:                        Purpose:                       Source:

Self-care                     To help patients to manage From referrers (GP/ interface
                              their own care under the   service)
                              supervision of a clinician


These stages are described in more detail below (key content, formats and locations)
and have been compiled in the form of recommendations for contents, formats and
locations.

Table 20: Point of Referral
Key content                                    Formats / Locations

 Information on type/s of provider on offer   Leaflets
  through this service – Physiotherapist,      Referrers (GP/Interface services)
  Osteopath and Chiropractor. Include
  information on each type of provider to      Web/downloadable content
  enable choice.                               NHS Choices
 Detail of options available for each         PCT websites (“services offered”)
  provider and contact information:
  o Name
  o Address
  o Contact details
  o Opening times
  o Description of service
  o Regulatory body
  o Symptoms treated
  o Treatments offered
  o Average waiting times
  o How to make an appointment

 How the referral works – clarity on next
  steps and support contacts if required.




                                         Section 2                                 Page 83
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Table 21: Starting treatment under AQP
Key content                                  Formats/Locations

 Overview of having treatment under AQP Leaflets
                                             Referrers (GP/Interface services)
 What kinds of services are available, what
  are they suitable for and what can I       Web/downloadable content
  expect? (Chiropractic, osteopathy,         NHS Choices
  physiotherapy)                             PCT websites (“services offered”)

 What happens if I do not attend my
  appointment?

 What happens if I’m not suitable for
  treatment?

 How can I complain?

 How can I provide feedback about the
  service that I’ve received? (link to NHS
  Choices/ Patient Opinion)


Table 22: Provider-specific patient information
(minimum as per community contract requirements)

Key content                                  Formats/Locations

 Provider-generated information about       Face to face clinician explanation
  treatments offered                         GP practice
                                             Treatment centre
 Information regarding other services (for
  onward referrals)                         Take-home leaflets
                                            GP practice
                                            Treatment centre

                                             Youtube videos
                                             Internet

                                             Link to NHS Choices/PCT website to
                                             access a list of links to relevant,
                                             accredited websites
                                             Internet



                                         Section 2                                Page 84
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Table 23: Self-care advice
Key content                                    Formats/Locations

Description of self-care treatments            Face to face clinician explanation
(exercises, pain management) including         GP practice
answers to questions:                          Treatment centre

 What is the treatment for?                   Take-home leaflets
 How do I do it?                              GP practice
 How long should I continue?                  Treatment centre
 What if my symptoms don’t get better?
 FAQs                                         Youtube videos
                                               Internet

                                               Link to NHS Choices/PCT website to
                                               access a list of links to relevant,
                                               accredited websites
                                               Internet




                                         Section 2                              Page 85
     Section 3

Recommendations for
    Qualification
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Section 3 INDEX

S3.1     Professional standards and codes of conduct that may apply to this service: .. 88

    S3.1.1 Chiropractic............................................................................................... 88

    S3.1.2 Osteopathy ............................................................................................... 88

    S3.1.3 Physiotherapy ........................................................................................... 88
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Section 3 – Recommendations for Qualification
We wish to include additional qualification questions around quality assurance and
accreditation for MSK services for back and neck pain.

    Please demonstrate how the clinician completing the initial assessment is suitably
     qualified to identify red and yellow flag indicators?
    Please demonstrate how you will fulfil the role of a service manager responsible
     for ensuring a high quality of clinical practice by all practitioners within the
     service, including necessary supervision of more inexperienced or junior staff and
     that all staff, including subcontractors, meet the requirements as set out in the
     service specification and the NHS Terms & Conditions?

S3.1      Professional standards and codes of conduct that may
          apply to this service:
Providers must be registered with the regulatory body appropriate to their profession
and must adhere to the professional standards and codes of practice set out by that
body.

S3.1.1    Chiropractic

Regulating body: General Chiropractic Council

Standards:
    General Chiropractic Council Code of Practice and Standard of Proficiency
     (effective from 30 June 2010).
    Continuing Professional Development (CPD) Mandatory Requirements
     (September 2004).

S3.1.2    Osteopathy

Regulating body: General Osteopathic Council

Standards:
    Code of Practice (May 2005)
    Standard 2000 – Standard of Proficiency (March 1999)
    Continuing Professional Development – Guidelines for Osteopaths

Note that this will be the new combined Osteopathic practice standards from September
2012.

S3.1.3    Physiotherapy

Regulating body: Health Professions Council




                                       Section 3                                Page 88
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Standards:
    Guidance of health and character (Jan 2010)
    Standards for the Good Character of Health Professionals
    Standards for the Health of Health Professionals
    Standards of Conduct, Performance and Ethics (July 2008)
    Standards of Proficiency (November 2007)
    Standards of Education and Training (September 2009)

Your guide to our standards for continuing professional development (May 2008)




                                      Section 3                                  Page 89
       Section 4

Commissioning Guidance
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc



Section 4 INDEX

S4.1      PART ONE: BACKGROUND AND CONTEXT ................................................. 92

     S4.1.1 Policy Context ........................................................................................... 92

     S4.1.2 Operating Principles of care delivery ........................................................ 93

     S4.1.3 Purpose and Scope of Guidance Document ............................................. 94

     S4.1.4 Engagement Approach ............................................................................. 94

S4.2      PART TWO: SERVICE SPECIFICATION GUIDANCE ..................................... 95

S4.3      PART THREE: COMMISSIONING GUIDE TO IMPLEMENTATION PROCESS
          111

S4.4      PART FOUR: RECOMMENDATIONS FOR FUTURE WORK ....................... 114

S4.5      PART FIVE: USEFUL RESOURCES ............................................................. 115

TABLES
Table 24: Commissioning guide to implementation process ........................................ 111
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


Section 4 – Commissioning Guidance

S4.1           PART ONE: BACKGROUND AND CONTEXT
S4.1.1         Policy Context

S4.1.1.1 Musculoskeletal Services

There are over 200 musculoskeletal conditions affecting millions of people, including all
forms of arthritis, back pain and osteoporosis. Looking at prevalence and impact:

       In Europe nearly one-quarter of adults is affected by long-standing MSK problems
        that limit everyday activity[1]
       It is estimated that up to 30% of all GP consultations are about musculoskeletal
        complaints and GPs have reported that it is the top clinical reason for visits (with
        musculoskeletal pain the most common presenting symptom)
       MSK conditions have a significant social and economic impact, with up to 60% of
        people who are on long-term sick leave citing MSK problems as the reason2 and
        patients with MSK forming the second largest group (22%) receiving incapacity
        benefits[2]
       Furthermore, it is recognised that whilst prevalent in all age groups the incidence
        of MSK disorders generally rises with age. As such the age, and proportion of
        older ages in the population, will further increase the demand for MSK Services
       Musculoskeletal disorders are the fifth highest area of spend in the NHS
        consuming £4.2 billion in 2008/9 [3]
       In the UK 16.5 million people have back pain[4]
       20% of the population present each year with a new onset or recurrences of an
        MSK problem[5].

Back and neck conditions frequently have an adverse influence on health and quality of
life for many individuals and can limit daily activities. While there is excellent care
available in some places, in many areas the quality of care is variable with poor access
and limited choice. Extending patient choice of provider for the treatment component of
care will help to address these issues by offering people with back and neck pain the
choice of qualified provider that would best meet their needs, in a framework that
delivers high quality.

S4.1.1.2 Any Qualified Provider

The 2010 health white paper ‘Equity and Excellence: Liberating the NHS’ and
supporting document ‘Liberating the NHS: Greater choice and control’ clearly signalled

[1]
   Department of Health, 2006. Musculoskeletal Services Framework
[2] CBI in associate with AXA, 2005. ‘Who care wins: absence and labour turnover 2005’
[3] ARMA 2010. Liberating the NHS: Transparency in outcomes – a framework for the NHS
[4] Clinical Standards Advisory Group for Back Pain. London, HMSO, 1994
[5] Clarke A & Symmons D. The burden of rheumatic disease. Medicine 2006; 34 (9): 333-335




                                                        Section 4                           Page 92
Ref: efbbc3f3-3e28-4078-815c-97d8bbe3d2ef.doc


the intention to provide greater choice for patients in delivery of healthcare. In July
2011, the Department of Health published ‘Operational Guidance to the NHS on
Extending Patient Choice of Provider’ setting out guidance regarding implementing ‘Any
Qualified Provider’ including musculoskeletal service for back and neck pain as one of
the initial service lines to be offered through AQP.

The goal is to enable patients to choose any qualified provider. Choice of provider is
expected to drive up quality, empower patients and enable innovation to support the
delivery of QIPP. Importantly, extending choice of AQP provides a vehicle to improve
access, address gaps and inequalities and improve quality of services where patients
have identified variable quality in the past.

S4.1.2         Operating Principles of care delivery

Key overarching principles for Any Qualified Provider that underpinned the development
of this pack:

     Choice: Extending patient choice of provider is intended to empower patients
      and carers, improve their outcomes and experience, enable service innovation
      and free up clinicians to drive change and improve practice. Patients should
      expect to play a central role in decisions about their condition and treatment and
      should benefit from high quality and accessible information to inform their
      decisions.
     Working in Partnership: Commissioners undertake to develop and maintain
      constructive working relationships with service providers and service users,
      carers, families, colleagues, lay people and wider community networks and
      working positively with any tensions created by conflicts of interest that may arise
      between the partners in care through the AQP model.
     Service Pathway Design: AQP provides the opportunity to review care pathways,
         improve access, address gaps and inequalities and improve the quality of services
         available.
        Acknowledging the Challenges: Introducing an extension to choice of provider for
         community services is inherently complex in the NHS system. Care in the planning and
         strong engagement throughout the process is key to successful implementation.

The following principles govern an AQP approach to contracting for services:

     Providers qualify and register to provide services via an assurance process that
      tests providers’ fitness to offer NHS funded services. The governing principle of
      qualification1 is that a provider should be qualified if they:
      o Are registered with CQC and licensed by Monitor (from 2013) where required,
         or meet equivalent assurance requirements;



1 Department of Health; 2011; Operating Guidance to the NHS: Extending Patient Choice of Provider.




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     o Will meet the terms and conditions of the NHS standard Contract which
        includes a requirement to have regard to the NHS Constitution, relevant
        guidance and law;
     o Accept the NHS prices;
     o Can provide assurances that they are capable of delivering the agreed service
        requirements and comply with referral protocols; and
     o Reach agreement with local commissioners on supporting schedules to the
        NHS standard contract including any local referral thresholds or patient
        protocols.
    Commissioners set local pathways and referral protocols which providers must
     accept
    Referring clinicians offer patients a choice of qualified providers for the service
     being referred to
    Competition is based on quality, not price. Providers are paid a fixed price
     determined by a national or local tariff.

S4.1.3    Purpose and Scope of Guidance Document

This document is designed to capture the key considerations and learning’s from the
development of the Any Qualified Provider (AQP) service specification for
musculoskeletal (MSK) services for back & neck pain.

The implementation pack is not designed to be prescriptive, nor is it designed to be a
‘one size fits all’ document therefore it is imperative that local commissioners develop
their own service specification based on their own local drivers and objectives for the
service.

This AQP Implementation Pack addresses the treatment component of the pathway. It
has been constructed to fit into different pathways that have been agreed locally,
whether there are existing triage services or multidisciplinary services providing
elements of the pathway.

Experience from existing services has indicated that by strengthening the triage and
referral processes within the pathway; and access to treatment within the community;
secondary care costs can be reduced and patient satisfaction increased.

S4.1.4    Engagement Approach

In developing this implementation pack the core delivery team has engaged with
commissioners, NHS providers, private providers, clinicians (including chiropractors,
osteopaths and physiotherapists), patient representative groups and relevant
professional bodies.

Annex 1 includes a list of those individuals and bodies involved in the development of
this document.



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S4.2         PART TWO: SERVICE SPECIFICATION GUIDANCE
All the notes within this section (S4.2) of the guidance document relate to relevant
sections within the service specification and are referenced accordingly.

1.1    Local drivers and strategic fit, and 2.1 Aims and objectives of service

The local drivers and associated objectives for choosing an AQP model for your service
will influence a number of details within your service specification, therefore it is
important to agree what you want to achieve at the outset. Commissioners should be
aware that different drivers will influence the market in distinct ways impacting the size
and shape of that market.

2.2    Service description

The service description is aligned to the currency model for the service specification.
Further information regarding currency, including the associated discussions around
average number of sessions, can be found in the accompanying currency paper. The
service model chosen for this specification is a package of care incorporating initial
clinical assessment; follow up appointments and guidance about self-care.

Initial clinical assessment:

Practitioners should undertake an initial clinical assessment to verify the
appropriateness of a referral, understand the patient history and condition, and, for
accepted referrals, determine the most appropriate package of care for that patient. The
provider should write to the GP with the patient’s agreed care package; this could be
achieved using a simple template letter that allows the GP to be notified without being
too onerous for the provider to complete.

For accepted referrals, the initial appointment would normally include advice and/or
treatment.

Follow up appointments:

The treatments included in scope for this service specification are as per NICE clinical
guidelines for low back pain, and NICE Clinical Knowledge Summaries for Back and
Neck Pain. It should be ensured that any treatments provided as part of this service
have robust, evaluated clinical evidence for use in back and neck pain.

Self-care:

It is important for providers to agree a ‘contract’ with a patient as part of their treatment
to ensure the patient takes increased responsibility for their own wellness, supported by
relevant self-care messages. This should happen at the outset of any treatment
program and continue to be reinforced throughout the duration.



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Discharge from service:

Discharge summaries are to be provided in a timely fashion whenever a patient is
discharged from the service to ensure that the GP is informed.

Additionally, it is mandated that all patients receive a copy of their management/self-
care plan upon discharge (whether they have completed the full package of care, or
have been discharged according to the local DNA policy).

Out of scope
Diagnostic tests:

Consideration should be given to the balance between the financial risk of allowing AQP
to request diagnostic tests (and this will impact the currency and therefore tariff) and the
impact on the locally established pathways. There is an impact if these requests need to
go via the GP, or to another appropriate level clinician (e.g. within an interface service a
senior or extended scope physiotherapist, or doctor may have authority to order certain
diagnostic tests). Commissioners will want to weigh up the risks and benefits in their
local context of including diagnostic test.

There may be a local need to include GP education around the appropriate use of
diagnostic tests for back and neck pain services as it is recognised that diagnostic tests
such as MRIs are rarely useful for planning the initial management of low back pain in
the absence of ‘red flags’. e.g. NICE guidelines state that MRI should only be offered for
non-specific back pain within the context of a referral opinion on spinal fusion1.

Patient transport:

Commissioners should consider the impact on currency (and therefore tariff) if patient
transport is included as a provider requirement. In designating patient transport as out
of scope commissioners must consider the process to request and manage patient
transport requests, and how this might align with existing systems and processes.

GP Education:

The service does not include any requirements to participate in formal GP training,
however it is recognised that investing in GP education benefits the overall performance
of an end-to-end MSK pathway for back and neck pain2.

Commissioners should consider their local requirements when determining whether to
include this aspect as part of their service, or commission it separately. Consideration
must be given to the need to manage multiple providers in the delivery of GP education


1
  http://www.nice.org.uk/CG88
2 Bernstein 2011, London Journal of Primary Care: Integrated Musculoskeletal Service Design by GP Consortia (Page 4).




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to ensure that GPs receive a coordinated approach, rather than multiple demands on
their time from various providers.

Recommendation of content for a GP education programme include, but are not limited
to:

      Referral criteria (and any prioritisation tools adopted locally)
      Appropriate use of diagnostic tests
      Pathway and services available
      The importance of self-care and appropriate levels of watchful waiting.

Public education:

The service does not include participation in a public health prevention programme for
service users although self-care is mandated as part of the package of care when a
patient presents.

Did Not Attend (DNA) and Unable To Attend (UTA):

Payment for DNA and UTA is for local determination. The DNA policy should be set by
the PCT in consultation with patient groups and stakeholders.

An example ‘Access Policy’ is that a patient is discharged after any DNA with both
patient and GP notified. There is then a 2 week grace period when the appointment can
be reinstated by the patient. Unable to Attend (UTA) can rebook, but the patient has to
rebook within 2 weeks of notifying the service of a cancellation. UTA within 24 hours is
treated as a DNA as the appointment is unlikely to be refilled at short notice.

2.3    Care pathway

There are a variety of pathways in place for MSK services; for example some include an
Interface Service, some include a Referral Management Service and others have
neither in place. As such, whilst we have endeavoured to include a pathway that
captures how this AQP service may form part of an MSK pathway, exact details such as
referral routes into the service and protocols for referring to other services will need to
be determined locally.

Onward referral protocols will be integral to ensuring success of the overall MSK
pathway, and due consideration should be given to ensuring that onward referrals are
only allowed if made by individuals with a high level of competency (such as that
required to identify red and yellow flags at initial clinical assessment), or as authorised
by the clinical lead.

Provision of other services

When introducing AQP for MSK services for back and neck pain it may be timely to
consider reviewing your existing care pathways to ensure that they align to best practice


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and deliver according to your local requirements. You may find it useful to consider the
capacity / provision of other services within the pathway e.g. pain management clinic, to
ensure that the referrals to AQP for back and neck pain services are appropriate (not a
‘bucket’ for patients who would derive more benefit from, and be more appropriate to
refer to, a pain management service instead).

Self-referral

Self-referral has been shown to improve access to patients and benefit the wider MSK
pathways. Self-referral has not been incorporated into the pathway agreed in this
service specification. In implementing AQP for back and neck pain services locally you
may consider the potential benefits from introducing a self-referral mechanism in your
pathway, allowing patients to self-refer to a service allowing telephone triage that can
provide advice on self-care or, if appropriate, provide a referral for treatment.1

The self-referral triage service would need to be commissioned separately as it would
effectively act as a ‘gate-keeper’ to the back and neck pain service, ensuring that those
patients who would benefit from self-care and watchful waiting are not immediately
referred on to providers for the back and neck pain service.

Referral management service (RMS)

In localities where there is a referral management service it may be appropriate to
include the RMS services as part of the agreed pathway and supporting processes. For
example, the RMS could host the information to support patient choice and may be able
to supply up-to-date waiting time information for patients.

It could also play an important role in detecting duplicate referrals and ensuring that
patients are only attending treatment at one provider.

Innovation

It is good practice to review referral routes and care pathways, and the opportunity for
innovation to deliver benefits (e.g. telephone triage, e-referral forms) on an on-going
basis. Commissioners may wish to consider the literature available regarding existing
examples direct access and telephone triage for physiotherapy services 2.

Providers should be encouraged to share with commissioners innovation that could
improve the efficiency and effectiveness of the service and/or the overall pathway.



1
    More information can be found in:
          NHS Evidence, Patient self-referral to musculoskeletal physiotherapy accessible via:
           www.evidence.nhs.uk/aboutus/Pages/AboutQIPP
        Department of Health, 2008. Self-referral pilots to musculoskeletal physiotherapy and the implications for improving
         access to other AHP services.
2 Working in Partnership Programme: Direct access to physiotherapy www.wipp.nhs.uk/uploads/gpdb/case_daphysio.pdf




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Innovation can also be applied to clinical patient management and should be shared
with commissioners in the same way.

Referral source and route

Whilst it is recognised that GP directed self-care is not part of this service specification,
it is deemed important to include this information so that providers are aware that
patients may have already received self-care guidance before being referred to the
service.

The referral source and route may differ according to local pathways, for example if you
have a referral management service (RMS) they could be central to processing
referrals. It is essential that the role of a GP as a gatekeeper to appropriate services is
recognised, especially where an RMS does not exist.

In agreeing the appropriate referral routes into the service, commissioners must
consider the importance of offering patient choice of provider and how different routes
may offer and facilitate this.

2.4    Any acceptance and exclusion criteria

In setting the referral criteria for the service it is important to consider the management
of those patients with back and neck pain that do not meet the criteria for this service. In
particular in ensuring that provision for them elsewhere in the pathway is recognised,
and the associated contracts for those services reflect the need to provide services for
these patients.

In determining these referral criteria, members of the MSK AQP project reference group
were keen to ensure that patients who present with primary peripheral limb condition
e.g. OA hip/knee and associated back and neck pain are not included. This is for two
reasons; firstly, the treatment for a primary limb problem with secondary back or neck
pain might present a small risk of serious underlying pathology being missed by an
inexperienced therapist and secondly, although manual therapy may be appropriate for
conditions other than ‘primary’ back and neck pain, such treatment may have been
commissioned elsewhere.

Again, it is important to consider the role that the GP has in ensuring appropriate
referrals to the service. In particular when determining if patients who represent with the
same condition will derive sustained benefit from an additional course of the same
treatment. Commissioners may wish to work with local clinicians in further defining
guidelines for this.

A package of GP education may be required to ensure understanding of the referral
criteria, any prioritisation tool used and the associated services available.




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Exclusions

Housebound patients: if commissioners wish to include housebound patients in scope
then additional consideration will be required assuring that the necessary training has
been undertaken, and appropriate insurance is in place.

Referral prioritisation

There may be existing structures, processes and clinical assessment tools in place to
quality assure the referrals that are sent to an MSK service. In implementing AQP for
part of the MSK pathway it will be necessary to consider whether it is appropriate to
apply these to the AQP service.

Furthermore, there are patient stratification tools available that may be used to aid
referral prioritisation, e.g. STarT Back1, or a locally developed tool such as ‘Ealing
Action Line2’ (to determine whether a patient is likely to improve quickly without referral),
and it would be necessary to engage with your local clinicians to determine the most
appropriate tools for your requirements. These tools can also be very useful in informing
appropriate levels of care, enabling providers to focus their resources to deliver an
efficient and effective service.

2.7       Access

Geographic scope

The requirements in this section will need to reflect the local drivers and objectives for
the service. If a commissioner states that providers need to ensure the service is
accessible to patients across the entire locality it may restrict the number and type of
providers you are able to attract to the market e.g. large providers that are able to
operate in more than one location.

Commissioners may choose to implement AQP for a service in order to address an
imbalance in a specific locality, in this instance tight requirements in this section will
support this objective.

Days / hours of service delivery

Commissioners may choose to specify core hours of delivery depending on local
circumstances, and if so the requirements in this section will need to reflect the local drivers and
objectives for the service. In stating that providers need to ensure that the service is available
for set hours this may impact the number and type of providers you are able to attract to the
market e.g. sole practitioners may be unable to provide a service that must be available for
extended hours throughout a week.

1
  Dr Jonathan C Hill et al. ‘Comparison of stratified primary care management for low back pain with current best practice (STarT
Back): a randomised controlled trial. ‘ The Lancet, Volume 378, Issue 9802, Pages 1560 - 1571, 29 October 2011.
2
  GP referrals for Musculoskeletal Conditions October 2009, NHS Ealing.
Available from the author: ian.bernstein@nhs.net




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Language

Commissioners will need to consider local arrangements when determining whether to
include translator services as part of the service specification for provider. If included,
the currency and local tariff will need to reflect this. If it is out of scope, commissioners
should consider local processes for requesting translators and ensure that these are
applicable and manageable with a larger provider base.

Commissioners will also need to consider local policy in determining whether the
translation service includes translation of written materials, or whether this is to be the
responsibility of the provider.

2.8    Whole system relationships

Depending on your locally agreed pathway and scope of service (whether a provider
can refer directly to other services) it may be necessary to include details in this section
of the specification that specify that providers will be required to signpost patients to
other named services (community, third sector) as appropriate.

3.0    Application service standards

As the services provided within this specification do not require providers to be Care
Quality Commission registered it is important that the commissioner is familiar with the
appropriate statutory regulatory bodies and their relevant professional standards.

While the statutory healthcare professional regulatory bodies play an important role in
regulating their registrants, their responsibilities and remit are different from those of the
CQC.

Professional standards:
Chiropractic

Regulating body:
General Chiropractic Council (www.gcc-uk.org)
Postal Address:
General Chiropractic Council
44 Wicklow Street
LONDON
WC1X 9HL

Telephone: + 44 (0)20 7713 5155
Fax:       + 44 (0)20 7713 5844
E-mail:    enquiries@gcc-uk.org




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Standards:
    General Chiropractic Council Code of Practice and Standard of Proficiency
     (effective from 30 June 2010)
    Continuing Professional Development (CPD) Mandatory Requirements
     (September 2004)

Osteopathy

Regulating body:
General Osteopathic Council (www.osteopathy.org.uk/)

Postal Address:
General Osteopathic Council
176 Tower Bridge Road
London
SE1 3LU

Telephone: +44 (0) 20 7357 6655
Fax:       +44 (0) 20 7357 0011
Email:     contactus@osteopathy.org.uk

Standards:
    Code of Practice (May 2005)
    Standard of Proficiency (March 1999)
    Continuing Professional Development – Guidelines for Osteopaths

Note that the Code of Practice and Standard of Proficiency will be replaced by the new
combined Osteopathic practice standards from September 2012.

Physiotherapy

Regulating body:
Health Professions Council (www.hpc-uk.org)

Postal address:
Health Professions Council
Park House
184 Kennington Park Road
London
SE11 4BU

Telephone: +44 (0)20 7582 0866
Fax:       +44 (0)20 7820 9684
E-mail:    policy@hpc-uk.org

Standards:
    Standards for the Good Character of Health Professionals
    Standards for the Health of Health Professionals


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       Standards of Conduct, Performance and Ethics (July 2008)
       Standards of Proficiency (November 2007)
       Standards of Education and Training (October 2005)
       Standards for Continuing Professional Development

Who assures the standards of the regulators?

Commissioners may also find it useful to consider the annual Performance Reviews
(see link at end of section) conducted and published by the Council for Healthcare
Regulatory Excellence (CHRE), which scrutinises and oversees the organisations that
regulate healthcare professionals across the UK (including the General Chiropractic
Council, the General Osteopathic Council and the Health Professionals Council).

The healthcare professional regulatory bodies have a statutory duty to protect and
promote the safety of the public. They do this by:

     Setting standards of education and training for the professions that they regulate;
     Maintaining a register of those who demonstrate they meet these standards;
     Setting standards of conduct, ethics and competence required to remain on the
      register;
     Investigating concerns about professionals who are registered and taking
      appropriate action where individuals might present a risk to the public; and
     Taking action against those falsely claiming to be a registered professional1.

Every year the CHRE reviews the performance of the regulators. It does this to check
that the regulators are carrying out their legal duties to promote the health, safety and
well-being of patients and the public. It also identifies areas where regulators are doing
well and those where they can improve. CHRE measures the regulators’ performance
against a set of standards that cover all areas of their work in:

       Standards and guidance
       Registration
       Fitness to practise
       Education and training

The CHRE reports its findings to the UK Parliament and also makes the Performance
Review public via their website. The 2010/2011 Performance Review can be found at:
http://www.chre.org.uk/satellite/402

Requirements regarding premises

A risk and suitability assessment of the venue must be undertaken and sent to the
commissioner.

1
 Department of Health, 2011. Enabling Excellence: Autonomy and Accountability for Health and Social
Care Staff



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Commissioners may want to request that providers include plans and/or photographs of
the premises they intend to use. Additionally, the commissioner may choose to inspect
the premises ahead of awarding any contract.

Complaints:

It is important that the local complaints policy is clear to patients so that patients know
who they can / should make a complaint to if they wish to. The complaints policy must
ensure that the providers, commissioners, regulatory bodies, NHS complaints service
and GPs are aware of any requirements to share complaint information with other
relevant organisations as appropriate.

Referral response times

The requirements in this section will need to reflect the local drivers and objectives for
the service. In stating that providers need to ensure access to the service in tight
timescales it may impact the number and type of providers you are able to attract to the
market.

The timescales for ‘urgent’ and ‘Non-urgent’ referrals have been determined based on
appropriate clinical guidance1.

Integrated governance

It is essential from a patient safety perspective that all providers demonstrate robust
processes to ensure a high quality of integrated governance.

Information technology and information governance

The requirements in this section reflect the NHS minimum information standards as
appropriate.

Providers should be Choose & Book (C&B) compliant, or working towards this.
Providers must be directly or indirectly bookable C&B, and should liaise with local
organisations (e.g. referral management centre) to enable this.

Recognising that these information standards may prove a barrier to entry to the market
for some smaller providers, providers may consider working with other providers in the
locality to federate in order to meet these requirements. Alternatively, providers may
wish to research options to lease a hosted electronic Patient Administration System
(PAS) that is accredited by the Department of Health.

Providers may consider federating in order to meet the NHS requirements regarding IT
and IG.


1
    Clinical Standards Advisory Group for Back Pain, Back pain report of a CSAG Committee on Back Pain. London. HMSO, 1994.




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Workforce

As this specification includes services provided by chiropractors, osteopaths and
physiotherapists it has not been possible to agree minimum workforce requirements
(e.g. minimum experience) across all three disciplines as the training and qualification
requirements are disparate. However, the specification includes details of a service
manager role with responsibility for ensuring high quality clinical practice by all
practitioners within the service, including necessary supervision of more inexperienced
or junior staff and that all staff, including subcontractors, meet the requirements as set
out in the service specification and the NHS standard Terms & Conditions

Along with reporting and monitoring of clinical incidents this should give assurance of
patient safety within all providers.

4.0 Key service outcomes

The service outcomes will need to reflect the local drivers and objectives for the service,
but in all cases due consideration should be given to the mechanisms required to collect
and analyse the data required to monitor and act on the delivery of these outcomes.

Clinical outcomes & Patient Reported Outcome Measures
(PROMs)
Agreeing a chosen PROM

It is recognised that clinical outcomes and PROMs for back and neck pain are areas
that lack consensus. There is an array of outcome measures available for MSK
conditions in general, in part due to the fact that they are complex and multi-dimensional
conditions.

As such, it is recommended that the chosen measures are agreed with local clinicians,
however the agreed tool must have been validated and be clinically meaningful.
Recognising the nature of back and neck pain, it is recommended that the chosen
PROM supports/enables a biopsychosocial assessment. Furthermore, in agreeing the
PROM tool consideration should be given to ease of use for patients particularly in
areas where English may not be the first language for many patients.

The Bournemouth Questionnaire (BQ) is suggested by members of the reference group
as it has been validated1 for back and neck pain, and has been used across
chiropractic, osteopathy and physiotherapy included as part of the Any Willing Provider
back and neck pain service for North East Essex PCT.



1 Bolton JE and Breen AC (1999) The Bournemouth Questionnaire: a short-form comprehensive outcome measure. I. Psychometric
properties in back pain patients. Journal of Manipulative and Physiological Therapeutics 22: 503-510
Bolton JE and Humphreys BK (2002) The Bournemouth Questionnaire: a short-form comprehensive outcome measure. II.
Psychometric properties in neck pain patients. Journal of Manipulative and Physiological Therapeutics 25: 141-148




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In addition to the BQ, a simple yet effective PROM such as the Global Clinical
impression Scale or Global Perceived Effect (GPE) is recommended to measure overall
improvement or worsening. These are post treatment PROMs.

Another example of a simple PROM that can be used is the 4 point Low Back Pain
Rating Scale1.

These simple PROMs can be easily gathered and reported, and can provide
commissioners with a quick indication of whether providers are delivering a service that
meets the clinical requirements of patients.

Recognising that clinical outcome measures and PROMs for MSK back and neck pain
is an area that lacks consensus and where work continues to be done, we have
included a recommendation for further work to be undertaken in this area. As such
commissioners should ensure that they review latest literature and guidance in this
area. For example the Chartered Society of Physiotherapists (CSP) are working to roll
out EQ-5D-5L as a preferred MSK PROM (note, this is across all MSK conditions and
not specifically back and neck pain).

Administration and analysis of PROMs

In deciding the chosen clinical outcomes and tools to measure these, consideration
must be given to the implications and practicalities of analysing the responses. PROMs
can be a useful tool in informing the clinician and their practice, and in primary research
it is necessary to ensure very high levels of returns and robust analysis; however this
level of activity and analysis may not be deemed necessary by commissioners. Local
commissioners may choose for PROMs to be recorded (and analysed) for only a certain
percentage of patients rather than all. This would need to be agreed at a local level; the
accompanying service specification assumes that PROMs should be collected for100%
of patients.

If requesting 100% of patients are monitored, commissioners must be aware of the
impact on the provider to deliver this and include in calculations of local tariff e.g. any
additional clinician time to provide patients with surveys, additional administrative time
to analyse results. A good PROM should be able to be completed by a patient without
guidance from a clinician, so it may be appropriate to assume minimal clinician time
required for this process as providers could rely on their administrative time to provide
and collate the PROM.

Further information about the Bournemouth Questionnaire

The BQ has scales that reflect seven of the dimensions of MSK back and neck pain e.g.
pain, anxiety, depression, activity. Each of the seven scales has 10 points, and the



1 Manniche, Low Back Pain Rating scale: validation of a tool for assessment of low back pain. Pain 1994, 57:317 – 326.




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patient completes a pre-treatment questionnaire and a post-treatment questionnaire
recording their scores on each of these 10 point scales.

In the example questionnaires provided on the website 1, questions 20 to 26 inclusive on
the pre-treatment questionnaire and questions 9-15 inclusive on the post-treatment
questionnaire are the actual BQ. It is these 7 questions that have been validated for use
in back and neck pain. All the other questions are included to provide more complete
information, and all of these additional questions can be deleted, replaced with others,
or retained depending on local needs. It is only the 7 identified questions that constitute
the outcome measure that is the BQ.

The commissioner may request that the provider returns the pre-treatment and post
treatment score for each scale. Alternatively (or in addition) they could return the sum of
the pre-treatment scores for all seven scales, and the sum of the post treatment scores
for all seven scales; and / or the analysis of the change in these scores.

The key question for any PROM is in determining what change in score equates to a
worthwhile, significant clinical improvement in the patient. Research undertaken using
the BQ has demonstrated that if there is a >30% change the patient is likely to have
made a significant clinical improvement2.

This information may inform local determination regarding PROMs, however as already
noted that members of the reference group are aware that as there is no consensus in
this area for MSK back and neck pain, it would be necessary to agree any targets
regarding outcome measures locally. It may be considered appropriate that no threshold
is set for the initial year of service, but that PROM data is collected and the analysis
used to inform the subsequent setting of thresholds.

Further information about the Global Perceived Effect (GPE) scale

The GPE measure has high face validity (Roer et al. 2006 3), and captures those
dimensions of the condition important to the individual patient. The GPE is a 7 point
ordinal scale ranging from much worse to complete recovery (Beurskens et al. 1996 4).
Scores from this measure can be dichotomised into success (very much improved and
much improved) and non-success (minimally improved, no change, minimally worse,
much worse and very much worse).




1
  http://www.aecc.ac.uk/research/bu-study.aspx
2
  Hurst H and Bolton J (2004) Assessing the clinical significance of change scores recorded on subjective outcome measures.
Journal of Manipulative and Physiological Therapeutics 27: 26-35
3 Roer NVD, Ostelo R, Bekkering G, van Tulder M, de Vet H. Minimal clinically important change for pain intensity, functional status,
and general health status in patients with nonspecific low back pain. Spine 2006;31:578-582.
4 Beurskens AJ, de Vet HC, Koke AJ. Responsiveness of functional status in low back pain: comparison of different instruments.
Pain 1996;65:71-76.




                                                            Section 4                                                   Page 107
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Indicative activity plan

Depending on your local reasons for implementing AQP and the market that you want to
create / manage, you may consider asking providers to demonstrate how they would
manage larger volumes of patients whilst still delivering service outcomes as required.

The NICE commissioning factsheet for low back pain published in 2009 stated that, ‘In
1998, the direct healthcare costs of all back pain in the UK were estimated at £1623
million – approximately 35% of these costs were related to services provided by the
private sector’1. Commissioners should consider the risk that offering MSK services for
back and neck pain through an AQP model may see some transfer of activity (for
costing purposes) from private sector to the NHS.

In order to estimate activity for the service as a whole, commissioners may wish to
consider analysis of current provider activity, available benchmarking tools and
publications such as NHS Evidence Musculoskeletal physiotherapy: patient self-referral
paper that documents that ‘Demand for NHS physiotherapy (predominantly
musculoskeletal care) is expressed per 1000 of the population, and averages 56/1000
(range 53 [urban] to 66 [rural] per 1000)’ . Note that data sources may not reflect the
exact scope of the service to be provided, and therefore may have limitations in
applicability.

B.4 – Service user, carer and staff surveys

Patient experience

Commissioners will wish to consider using a patient experience questionnaire that is the
same as / comparable to existing patient satisfaction questionnaires in order to provide
a useful comparison. If not already included in a template questionnaire, commissioners
should consider including a question that allows them to identify ‘upselling’ of services
(e.g. NHS patients offered treatments privately) so that they are able to monitor this via
patient experience returns.

In establishing a new service it may be preferred to mandate patient experience
questionnaires for all patients in the first year of service, but perhaps amend this in
subsequent years.

Patient experience questionnaires are only one mechanism for gaining feedback from
patients, as per the details in the service specification the provider should ensure
appropriate mechanisms are in place to engage patients on a wider basis and the
commissioners may also consider patient engagement activities, particularly in the first
year of the new service.

1
  NICE clinical guideline 88 Low back pain: commissioning factsheet, 2009. National Institute for Health
and Clinical Excellence




                                               Section 4                                      Page 108
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B.6 – Information Management

Monitoring

As offering a back and neck pain service via AQP will be new to the majority of
commissioners, it is strongly recommended that robust, regular monitoring of the
service is undertaken during the first year of service. Monitoring and review
requirements (including potential use of CQUIN) may be amended in subsequent years
depending on the analysis of year one performance.

When determining the frequency and scale of monitoring requirements commissioners
should consider the impact of multiple providers on this process.

As is good practice, commissioners should also ensure that reporting requirements are
appropriate and do not add additional ‘burden’ to the system (both provider and
commissioner) unnecessarily e.g. the information is not used, provides no benefit. To
this end, commissioners may wish to consider developing a random sampling approach
for providers to collect patient experience and PROM information (if you have a RMS
this could aid administration of this)

Commissioners should be aware that outcomes for the service will be influenced by a
number of factors, including but not limited to, the experience of referring GP, the
locality, the severity of presentation. Audits must be considered an important tool in
contract monitoring in order to ensure that this information is considered when reviewing
performance. Additionally, it may be considered useful to include a mandatory field on
the monthly data return to capture if the referral was inappropriate. Given sufficient
numbers of rejections this might facilitate a subsequent education/knowledge based
discussion between pathway manager, provider and GP.

It is recognised that introducing AQP for services will likely attract a greater number of
providers to the market, and this will have an impact on the commissioner’s contract
management responsibilities. Therefore, it may be timely for commissioners to consider
operating the service (or wider pathway) as part of a managed service or prime vendor
model, essentially ‘sub-letting’ the AQP service and associated monitoring requirements
to a single provider. The commissioner then manages that sole provider accordingly,
but must ensure in designing that service specification that due attention is given to
prevent undue bias or influence when offering patient choice. There are instances
where this model has already been applied and further information can be found on the
internet.1




1
 http://www.pulsetoday.co.uk/pcarticle-content/-/article_display_list/12202618/commissioning-whole-pathways-to-drive-
up-quality




                                                      Section 4                                             Page 109
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Review meetings

There is a resource requirement to undertake review meetings and this will be
dependent on the size of the market and therefore monitoring commitments and the
frequency of these should be considered with this in mind.

It is suggested that as a minimum a review meeting will be conducted after three
months of service with subsequent annual reviews unless significant issues arise.
However, the commissioner retains the right to amend this monitoring schedule.

The review meeting will encompass a review of performance, compliance with
monitoring and reporting requirements, complaints, and any other issues.




                                    Section 4                            Page 110
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S4.3       PART THREE: COMMISSIONING GUIDE TO
           IMPLEMENTATION PROCESS
Table 24: Commissioning guide to implementation process
Phase of       Task/Milestone                Notes/Comments
Implementation

Analysis        Decision made about          Local engagement
                which services –
                agreement with CCGs
                around the scope and
                scale of each AQP
                service
                Service variation process    Involves identifying current contracts and
                initiated with providers –   scope; implications for changes; providing
                may lead to minimum six      notice of service variation/termination if
                months’ notice required.     appropriate.
                Market Assessment –          Involve:
                planning of market            Demand side review, identifying need,
                structure desired.             access and performance of the market
                                              Supply side review, identifying current and
                                               future potential provision in the area,
                                               viability of service provision and impact of
                                               expanding.
                                              Optimal market structure designed, based
                                               on modelling local market – e.g. extending
                                               or restricting number of providers
                                               depending       on    demand/supply    side
                                               dynamics.
Investigation   Development of business      Establishment of a business and
                and implementation plan      implementation plan helps clarify the details
                for each AQP service –       of the changes proposed, case for change,
                agreed with CCGs.            outcomes desired and approach to delivery.
                                             This can then be used in the engagement
                                             process to provide clarity and assurance
                                             towards the proposed changes.
                Consultation with            Depending on the extent of proposed
                stakeholders, including      service changes – to pathway, supply of
                patients OSC’s and           services etc. need to engage locally to
                H&WBs due to service         ensure local ownership of changes to the
                model changes                service and / or formal public consultation.
                Develop service              Include: revised pathways, service


                                       Section 4                                   Page 111
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Phase of       Task/Milestone              Notes/Comments
Implementation

               specifications, currency    specifications, currency, referral protocols
               and KPIs for each AQP       and thresholds, contract requirements and
               service                     performance framework including clinical
                                           reviews for each service line and publish on
                                           Supply-2-Health site for potential providers
                                           to register for.
               Provider engagement         Engagement with existing and potential
               events                      providers around AQP and the local
                                           requirements if they choose to register and
                                           understand expectations, obligations and
                                           process for engagement with the AQP
                                           process.
Delivery       Publish advert and           Give clear time sets for potential providers
               qualification                 to complete the application so all
               requirements                  successful providers enter the pool and
                                             begin contracted work at the same time.
                                            Don’t underestimate the time it takes to
                                             get provider clarifications and work with
                                             providers to complete questionnaires to
                                             allow providers through. (if this is not
                                             done some providers may not be
                                             approved in timeframe allocated – e.g.
                                             existing NHS providers).
               Undertake evaluation of     Agreement of providers for AQP service.
               providers in order to
               become registered
               providers
               Mobilisation phase –        Ramp up for implementation phase
               contracts, choose and       including: finalisation of contracts; getting
               book entry, etc.            IT/systems in place if required; providers
                                           preparing to take on AQP services; CCGs
                                           and GP’s/community services prepared for
                                           offering choice – protocols, processes.
               AQP service starts




                                       Section 4                                 Page 112
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Additional guidance regarding engagement approach when implementing AQP
locally

In developing your local AQP specification it is beneficial to invite the potential provider
groups that you wish to provide the service to contribute towards service design and
implementation, including developing appropriate documentation to support the service.
By including disciplines wider than just physiotherapy, e.g. chiropractic and osteopathy,
it is strongly recommended that commissioners engage with all relevant disciplines to
work together during this process to ensure any potential fragmentation of the service is
reduced.

Additionally, commissioners must consider the market that they wish to create and
manage through implementing a service via AQP. In doing so, they should also
consider that many potential providers may not be aware of the Supply2health
procurement portal and therefore an exercise to engage potential providers is essential.

Commissioners should also consider the role of GPs in ensuring successful adoption of
the AQP service. It may be useful to undertake GP education about the new service,
and in particular the different disciplines that may provide the service, to ensure that
patients receive clear messaging about what to expect from the service and their
treatment.




                                         Section 4                                 Page 113
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S4.4        PART FOUR: RECOMMENDATIONS FOR FUTURE WORK
Recommendations for future work

Clinical outcome measures:

The work presents an opportunity to develop a degree of standardisation applicable
across all relevant disciplines regarding clinical outcome measures, including patient
reported clinical outcome measures (PROMs).

Currency:

Further work is conducted to review and/or further develop the clinical evidence base for
average number of treatment sessions for back and neck pain for optimal outcomes. It
may be pertinent to build upon findings following the introduction of AQP for this area.

Alternative pathways:

As stated throughout, this implementation pack and the service specification included
reflect one potential model of care for delivering MSK Services. It is recognised that
there are many other pathway options available, and as AQP service specifications are
developed for services that may better meet the requirements of different localities and
their associated MSK pathways, these should be shared via Supply2Health.

NHS Outcomes Framework:

It may be necessary to amend the service specification, and align other service
specifications, so that they align with the NHS Outcomes Framework 2012/13 (due for
publication December 2012 / January 2013) and the new NHS standard contract (due
for publication December 2012).




                                        Section 4                               Page 114
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S4.5     PART FIVE: USEFUL RESOURCES
Additional useful resources

   Musculoskeletal Services Framework, 2006. Department of Health
   Self-referral pilots to musculoskeletal physiotherapy and the implications for
    improving access to other AHP services, 2008. Department of Health
   Delivering Quality and Value Focus On: Musculoskeletal Interface Services,
    2009. NHS Institute for Innovation
   National costing report: low back pain, 2009. National Institute for Health Clinical
    Excellence
   Clinical guidelines CG88 Low back pain: Early management of persistent non-
    specific low back pain, 2009. National Institute for Health and Clinical Excellence
   NICE clinical guideline 88 Low back pain: commissioning factsheet, 2009.
    National Institute for Health and Clinical Excellence

NHS North East Essex

         Back and neck pain services case study: Manual Therapies Back & Neck
           Service, NHS North East Essex: http://healthandcare.dh.gov.uk/back-
           and-neck-pain-services.
   J Hartvigsen, N E Foster, P Croft, ‘We need to rethink frontline care for back
    pain’. Editorial BMJ 2011;342:d3260
   The following paper, evaluating the NHS North East Essex service, has been
    accepted for publication:
   Mark Gurden, Marcel Morelli, Greg Sharp, Katie Baker, Nicola Betts, Jennifer
    Bolton . ‘Evaluation of a GP referral service for manual treatment of back and
    neck pain’. Primary Health Care Research & Development.

Choose and Book

   Guidance on implementing and utilising Choose and Book:
    http://www.chooseandbook.nhs.uk/staff
   Chartered Society of Physiotherapy guidance on implementing Choose and Book
    for Physiotherapy:
    http://www.csp.org.uk/professional-union/practice/choose-book

Community Information Data Set (CIDS)

   The NHS Information Centre support page for CIDS including a CIDS readiness
    assessment tool and FAQs:
    http://signposting.ic.nhs.uk/?k=cids
   Information Standards Board for Health and Social Care notice of new standard –
    Community Information Data Set:
    http://www.isb.nhs.uk/library/standard/111



                                       Section 4                               Page 115
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NHS Minimum standards for IT and information governance

   NHS Information Governance statement of compliance:
    http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/igsoc
   NHS Information Governance toolkit (contains all relevant policies and standards
    on this topic):
    https://www.igt.connectingforhealth.nhs.uk/
   NHS Confidentiality standards:
    http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/confid
    entiality
   NHS Record Keeping standards:
    http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/record
    s
   Principles of information security:
    http://www.connectingforhealth.nhs.uk/systemsandservices/infogov/securit
    y
   NHSMail - the standard for the safe transfer of encrypted NHS-related patient
    identifiable data:
    http://www.connectingforhealth.nhs.uk/systemsandservices/nhsmail

Information Commissioner statement on the use of encryption relating to the use,
storage and transfer of personal data

http://www.ico.gov.uk/news/current_topics/Our_approach_to_encryption.aspx

Workforce good practice around information handling, and transfer

   Learning to Manage Health Information: a theme for clinical education.
    http://www.connectingforhealth.nhs.uk/systemsandservices/icd/eice/learnin
    g
   “NHS Connecting for Health (2009) Learning to Manage Health Information: a
    theme for clinical education “
    http://www.connectingforhealth.nhs.uk/systemsandservices/icd/eice/learnin
    g




                                     Section 4                              Page 116
    Annex 1

Acknowledgements
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Annex 1: Acknowledgments

Reference Group Members
Dr. Ian Bernstein          Musculoskeletal Physician and GP trainer NHS Ealing
Jill Gamlin                Consultant Physiotherapist, Musculoskeletal Physiotherapy
                           Business Unit, Cambridgeshire Community Services NHS
                           Trust
Sarah Esson                Senior Project Manager - Acute Commissioning
North East Essex Primary
Care Trust
Mark Gurden                Chiropractor, provider for North East Essex Primary Care
                           Trust
Greg Sharp                 Osteopath, provider for North East Essex Primary Care
                           Trust
Esme Young                 Hillingdon CCG
Ros King                   Operations Director, Central London Healthcare
Tera Younger               Patient representative, NHS North West London
Trevor Begg                Patient representative, NHS North West London
Seema Kathuria             Non-Acute Commissioning, NHS Hillingdon
Glyn Wise                  Procurement Account Manager, Healthcare Commissioning
                           Services, NHS Worcestershire
Mike Hodgson               Chief Executive, Hodgson Physiotherapy Services
Patrick Harding            Physiotherapist, Clinical Lead In-patient Rehabilitation,
                           Central London Community Healthcare NHS Trust
Dr Sarah Schofield         GP North Baddesley and Chairman West Hampshire
                           Clinical Commissioning Group
Rachel Wakefield           Associate Director Programme Planned Care
South Central Strategic
Health Authority
Andrew Walton              Chief Executive, Connect Physical Health
Marian Knight              Category Manager, NHS Lincolnshire
Professor Jenni Bolton     Anglo-European College of Chiropractic
Natalie Beswetherick       Chartered Society of Physiotherapists
Steve Tolan                Chartered Society of Physiotherapists




                                       Annex 1                                  Page 118
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Professional bodies
British Osteopathic Association
General Osteopathic Council
General Chiropractic Council
Chartered Society of Physiotherapists
Core Team
Thirza Sawtell                 Director, Delivery Support Unit, NHS North West London
Lynelle Hales                  Deputy Director, Delivery Support Unit, NHS North West
                               London
Rhian Butler                   Project Manager, Delivery Support Unit, NHS North West
                               London
Lucy Sutton                    Associate Director for End of Life Care Programme and
                               AQP Lead NHS South Central
Keith Douglas                  Director of Contracting, Southampton, Hampshire, Isle of
                               Wight, & Portsmouth PCT Cluster
Christine Kirkpatrick          Strategy Manager, Strategy and Commissioning
                               Development, NHS London
Annabelle Walker               AQP lead for MSK, Department of Health
Christopher Foster-McBride PbR team, Department of Health
Mark Lambert                   AQP Qualification team, Department of Health

Development of this pack

The core team would like to thank everyone named above and also the many
individuals within the professional bodies who have directly contributed to the
development of this pack. Over the past three months the team have we have received
in excess of 300 comments and have acted on and incorporated these throughout the
pack as appropriate.

The generosity of all involved in sharing their knowledge and expertise, as well as their
time, has enabled the team to deliver this implementation pack. Thank you.




                                         Annex 1                                Page 119
   Annex 2

Considerations
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Annex 2: Considerations (to be completed)
Please note Annex 2 is being updated - the following link will take you to the
latest version of this document.

http://www.supply2health.nhs.uk/AQPResourceCentre/Pages/Annex2.aspx




                                    Annex 2                           Page 121
         Annex 3

Public Sector Equality Duty
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Annex 3: Public Sector Equality Duty
The Equality Act 2010 replaces the previous anti-discrimination laws with a single Act
making it easier for people to understand. It also strengthens the law in important ways,
to help tackle discrimination and inequality. The Public Sector Equality Duty, which
came into effect on 5 April 2011, sets out the responsibilities a public authority must
undertake in order to ensure an environment that fosters good relations between
persons of differing protected characteristics. Protected characteristics under the
Equalities Act 2010 are age, disability, gender reassignment, pregnancy and maternity,
race, religion or belief, sex, sexual orientation. The Equality Duty has three aims. it
requires public bodies to have due regard to the need to:

    eliminate unlawful discrimination, harassment, victimisation and any other
     conduct prohibited by the Act;
    advance equality of opportunity between people who share a protected
     characteristic and people who do not share it; and
    foster good relations between people who share a protected characteristic and
     people who do not share it.

Commissioners should have regard to the Public Sector Equality Duty when
commissioning services for patients. For more information please visit the Department
of Health website and search for 'Equality and Diversity'.




                                        Annex 3                                 Page 123
Annex 4

Glossary
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Annex 4 – Glossary

Audit                     Clinical audit is a process that has been defined as "a quality
                          improvement process that seeks to improve patient care and
                          outcomes through systematic review of care against explicit criteria
                          and the implementation of change".

                          The key component of clinical audit is that performance is reviewed
                          (or audited) to ensure that what should be done is being done, and
                          if not it provides a framework to enable improvements to be made.
Any Qualified             Means that when patients are referred (usually by their GP) for a
Provider                  particular service, they should be able to choose from a list of
                          qualified providers who meet NHS service quality requirements,
                          prices and normal contractual obligations1.
Caldicott                 A Caldicott Guardian is a senior person responsible for protecting
Guardian                  the confidentiality of patient and service-user information and
                          enabling appropriate information-sharing2.
Care Pathway              Means an evidence based plan of goals and key elements of care
                          for a service user that facilitates the communication, coordination of
                          roles and sequencing of the activities across their components of
                          care. The aim of which is to enhance the quality of care by
                          improving service user outcomes, promoting service user safety,
                          increasing service user satisfaction and optimising the use of
                          resources.
Care Quality              Means the Care Quality Commissioning established under the 2008
Commission                Act.
Choose and Book Means the national electronic booking service that gives patients a
                choice of place, date and time for first hospital or clinical
                appointments.
Currency                  Means the unit for which payment is made and can take a variety of
                          forms including episodic, block and package of care. The NHS
                          costing manual sets out the principles for arriving at a total cost for
                          each currency
Did Not Attend            Means where the appointment did not take place where the patient
                          failed to attend.
Discharge                 Means a document issued to the service user by the lead
Summary                   Healthcare Professional or Care Professional of the service


1
 Department of Health; 2011; Operational Guidance to the NHS: Extending Patient Choice of Provider.
2
 Department of Health; accessed November 2011;
www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Patientconfidentialityandcaldicottguardians/DH_4100563




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                              responsible for the service user’s care or treatment for the service
                              user to use in the event of any query or concern immediately
                              following discharge, containing information about the service user’s
                              treatment, including without limitation:
                               The dates of the service user’s referral or assessment;
                               The dates of the service user’s discharge;
                               Details of any care plan or treatment delivered;
                               Name of the service user’s responsible lead healthcare
                                professional or care professional at the time of the service user’s
                                discharge;
                               Any relevant or necessary information or instructions;
                               Contact details for the provider;
                               Any immediate post-discharge requirement for the GP or Referrer
                                or other healthcare provider;
                               Any planned follow-up arrangements; and
                               The name and the position of the person to whom questions
                                about the contents of the discharge letter are to be addressed;
                                and complete and accurate contact details (including telephone
                                number) for that person.
In-scope, Out of              In scope refers to the services that are to be commissioned as part
scope                         of this service, and as defined within the service specification. If
                              anything is considered out of scope, it will need to be
                              commissioned separately.
Interface Service Any service (excluding Consultant Led Services) that incorporates
                  any intermediate levels of triage, assessment and treatment
                  between traditional Primary Care and Secondary Care. Interface
                  Services include assessment services and referral management
                  centres. It does not include:
                   Arrangements established to deliver primary, community or Direct
                    Access Services, outside of their traditional setting
                   Non-Consultant Led Services for mental health run by Mental
                    Health Trusts
                   Referrals to Practitioners with Specialist Interests for triage,
                    assessment and possible treatment, except where they are
                    working as part of a wider Interface Service arrangement.

                              Referral To Treatment (RTT) Periods to Interface Services are
                              included in the 18 weeks targets. These are no longer central NHS
                              targets, but are part of local contracting targets1.
Local Authority               Means a county council in England, a district council in England or

1
    Source: http://www.datadictionary.nhs.uk/ accessed 09.10.2010




                                                          Annex 4                         Page 126
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                    a London Borough Council.
Monitor             Means the public office established under the Health and Social
                    Care (Community Health and Standards) Act 2003 with
                    responsibility for authorising NHS Foundation Trusts and
                    accountable to Parliament, and continuing under section 31 of the
                    2006 Act and any successor body or bodies from time to time, as
                    appropriate.
NHS                 Means the National Health Service in England.
NHS Constitution Means the constitution for the NHS in England set out in Law
                 and/or Guidance from time to time which establishes the principles
                 and values of the NHS in England and sets out the rights, pledges
                 and responsibilities for patients and public and staff.
NHS Foundation      Means an NHS Foundation Trust as defined in Section 30 of the
Trust               2006 Act.
NHS Trust           Means a body established under the Section 25 of the 2006 Act.
National Institute Means the special health authority responsible for providing
for Health and     national guidance on the promotion of good health and the
Clinical           prevention of ill health (or any successor body).
Excellence or
‘NICE’
National            Means those standards applicable to the provider under the Law
Standards           and/or Guidance as amended from time to time.
National Tariff     Means the list of prices published from time to time by the
                    Department of Health and applied in line with the Department of
                    Health guidance relating to National Tariff construction and coding,
                    charging and recording methodologies.
Package of Care     Means any assessment, treatment, nutrition, support,
                    accommodation or other elements of care to be provided under the
                    service and relating to a referral or an emergency presentation.
Patient Booking     Means the procedures for patient booking set out in Module E of
                    the contract.
Patient Choice      Means the commitment to free choice in elective care, which
                    requires that all patients who require a referral for elective care
                    from their GP or primary care professional for a first appointment
                    shall be able:
                     To choose to be treated by any provider that meets relevant
                      eligibility criteria and registered as a Qualified Provider.
                     To choose the time and date for their booked appointment, at the
                      time they are referred.



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Patient         Means a plan to deliver services that are appropriate to the needs
Management Plan of the service user and that pays proper attention to the service
                user’s culture, ethnicity, gender, age and sexuality and takes
                account of the needs of any children and carers.
Price/Tariff                   Price/tariff = Set price for a given currency unit. Has the meaning
                               given to it in Clause 7.2 of the Contract Terms and Conditions.
Principles and                 Means the rules of procedure published from time to time by the
Rules of                       Department of Health, relating to the commissioning and provision
Cooperation and                of NHS services, to support cooperation and competition in the
Competition                    interests of patients and taxpayers in relation to:
                                Commissioning and procurement.
                                Cooperation and collusion.
                                Conduct of individual organisations.
                                Mergers and vertical integration.
Qualification                  Means the process of registering providers to be eligible to deliver
Process                        services to ensure that all providers offer safe, good quality care,
                               taking account of the relevant professional standards in clinical
                               services areas. The governing principles of qualification1 is that a
                               provider should be qualified if they:
                                are registered with CQC , where a regulated activity is being
                                 provided2 and licensed by Monitor (from 2013) where required, or
                                 meet equivalent assurance requirements3
                                will meet the Terms and Conditions of the NHS Standard Contract
                                 which includes a requirement to have regard to the NHS
                                 Constitution, relevant guidance and law
                                accept NHS prices
                                can provide assurances that they are capable of delivering the
                                 agreed service requirements and comply with referral protocols;
                                 and
                                reach agreement with local commissioners on supporting
                                 schedules to the standard contract including any local referral
                                 thresholds or patient protocols
Quality Incentive Means a payment due to the Provider for having met the goals set
Payment           out in the Quality Incentive Scheme.
Quality Incentive Means any performance incentive scheme set out in Section 4 of
Scheme            Module B of the Contract.
Red flags                      Red flags are indicators in the history or examination that indicate
                               possible serious underlying pathology such as infection, cancer,


1
    Department of Health; 2011; Operational Guidance to the NHS: Extending Patient Choice of Provider.
2
    http://www.cqc.org.uk/sites/default/files/media/documents/8798-cqc-the_scope_of_registration_revised.pdf



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                           soft tissue trauma and fractures, cord compression, cauda equine
                           syndrome, inflammatory and vascular disorders1.
Referral                   Many PCTs have set up referral management services to act as a
Management                 collection point for referrals before they are forwarded to secondary
Service                    care. Different models have been developed: some act purely as
                           information gathering centres, others clinically assess and triage
                           referrals eg clinical assessment centres.

                           The key is that these services concentrate on working with primary
                           and secondary care clinicians so they have the information
                           necessary to make high quality, consistent referrals2.
Referrer                   Means:
                            The NHS Body that refers a service user to the provider for
                             assessment and /or treatment.
                            The service user’s GP
                            Any organisation, legal person or other entity which is permitted
                             or appropriately authorised in accordance with the Law to refer
                             the service user for assessment and/or treatment by the Provider.
                            Any individual service user who presents directly to the Provider
                             for assessment and/or treatment if self-referral is included within
                             the service specifications.
Service manager Responsible for overall service delivery including, but not limited to:
                 Ensuring a high quality of clinical practice by all practitioners
                  within the service, including necessary supervision of more
                  inexperienced or junior staff
                 That all staff, including subcontractors, meet the requirements as
                  set out in the service specification and the NHS Terms &
                  Conditions
Service User               Means a patient, service user, client or customer of a
                           Commissioner or any patient, service user, client or customer who
                           is referred or presented to the Provider or otherwise receives
                           services under this Agreement.
Specifications             Means the service requirements set out in this document.
Staff                      Means all persons (whether clinical or non-clinical) employed or
                           engaged by the Provider (including volunteers, agency, locums,
                           casual or seconded personnel) in the provision of the Services or
                           any activity related to, or connected with the provision of the


1 Clinical Standards Advisory Group for Back Pain. Back pain report of a CSAG Committee on Back Pain, London: HMSO, 1994.
2 Adapted from, NHS institute for innovation
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/demand_and
_capacity_-_demand_management.html




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                        Services.
Yellow flags            Yellow flags are indicators in the history or examination of
                        psychosocial (surmountable) obstacles to recovery. These predict
                        an increased risk of delay in recovery. Examples include:
                         Presence of a believe that back pain is harmful or potentially
                          severely disabling
                         Fear-avoidance behaviour (avoiding a movement or activity due
                          to a misplaced anticipation of pain) and reduced activity levels
                         Tendency to low mood and withdrawal from social interaction
                         An expectation that passive treatments rather than active
                          participation will help1.




1
 NZGG (2004) New Zealand acute low back pain guide. New Zealand Guidelines Group. www.nzgg.org.nz [Free
Full-text]



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