ࡱ>  tVbjbj lhhCM,/$P|ats!s!!!!###aaaaaaascfa##"###a??!!-ab&b&b&#d?8!!ab&#ab&b&Ww$\!`+J4R$ hY,aa0aYf^%fX$\$\f]##b&#####aa%p###a####f######### :  PRIMARY CARE DEVELOPMENT 4.1.5 ENHANCED SERVICE SPECIFICATION FOR THE VIOLENT PATIENT SERVICE 1 SERVICE OUTLINE All Primary Care Trusts are required to have access to a Directed Enhanced Service (DES) to cover support services to staff and the public in respect of the care and treatment of patients who are violent. The right of a Provider to remove a violent patient is extended to safeguard all those who might have reasonable fears for their safety. These include members of the Providers staff, other patients and any other bystanders present where the act of violence is committed or the behaviour took place. Violence includes actual or threatened physical violence or verbal abuse leading to a fear for a persons safety. Violent behaviour may include: behaviour which has become a serious threat to staff, other patients, relatives or visitors presenting a risk of harm or serious injury to a member of staff, other patients, relatives or visitors deliberate use of physical violence/contact to inflict actual harm towards a member of staff, other patients, relatives or visitors the purposeful and wilful damage to or destruction of property Depending on the gravity of the incident, the Primary Care Trust might wish to explore with the Provider the additional support that might be provided to enable the patient to be retained on their list. In other cases where patients are subject to immediate removal where the police have been called to the incident will be placed with a provider of this enhanced service. Patients subject to the immediate removal from providers will be registered with the service provider appropriate to their locality. SERVICE AIMS The enhanced service is for the provision of general medical services. The enhancement of the resources available for the provider of the service facilitates the treatment of the patient in a way that minimises the risk of violence or the impact of disruptive behaviour. The patients access to wider facilities may be restricted. Additionally, such patients often have complex and wide-ranging health and social care needs. The service should provide a stable environment for the patient to receive continuing health care and address any underlying causes of aggressive behaviour. This may include working with social services and other agencies to improve the patients behaviour or to prevent further deterioration. SERVICE REQUIREMENTS The service provider shall ensure that: patients who have been subject to immediate removal from a provider patient list are provided a stable environment for the patient to receive continuing health care, addressing any underlying causes of aggressive behaviour and providing a safe environment for the individuals involved in delivering that treatment it promotes a continuing understanding of the NHS health and social care system to encourage the patient to use the service in a responsible, appropriate and safe way in the future it demonstrates joint working with other primary care practitioners, social services and other agencies to try and treat any clinical and underlying causes of disruptive behaviour to prevent further deterioration it works within any local arrangements for dealing with violence that has been entered into by the Trust with the Local Medical Committee (LMC), the police, other agencies and other parts of the NHS it provides medical care for patients who have been subject to immediate removal from a general provider patient list it maintains the patients registration for at least three months it is mindful of the need to protect patient confidentiality by avoiding data flows which identify individuals it shares information between professionals and agencies to ensure that appropriate services are provided and safe working practices are adopted appropriate security facilities are available to protect the provider and other patients in upgrading security, it should not be to adversely affect the outward appearance of the provider premises where care is provided in a way which might make other patients uneasy about the security environment. Security should, wherever possible be discrete but effective rather than overt The provider shall: provide a thorough assessment of the patients clinical, psychological and social needs especially those which may result in unrealistic expectations and which may have led to physical or verbal aggressive behaviour in the past provide time to educate the patients and his/her family or carers on the best way to obtain good quality and continuing services from primary care and the NHS endeavour to work with other Primary Care Practitioners, Social Services and other agencies to identify and treat any clinical and underlying causes or disruptive behaviour to prevent further deterioration ensure that patients are clearly informed that they are having care provided within a Violent Patient Service specifically because of the previous violent behaviour. It should be made clear to patients that they are not being excluded but that their behaviour compromises their right to have access to normal arrangements and locations for receiving those services provide stability to ensure improved doctor-patient relationship in which both the doctor and patient can work constructively together. The intention is to provide a wide range of health and social services review the provision of care to a violent patient every three months undertake to complete an adverse incident review for every incident. If the patient commits a criminal act whilst under the care of the service, normal prosecution should take place and a revised risk assessment should be undertaken undertake a risk assessment for every process that shall be undertaken during the provision of the violent patient service using the Primary Care Trust risk assessment tool in Appendix 1. The Primary Care Trust Policy for minimising and dealing with violence and aggression in the work environment contains appendices which identify areas which may need to be considered identify a member of its staff as a risk management coordinator and shall compile a risk register of all identified risks, providing a copy to the locality Senior Primary Care Commissioning Manager. Sample risk register and guidance is available in Appendix 2 ensure that all clinical information relating to the violent patient is forwarded to the patients own General Practitioner (GP) held lifelong record, including the completion of the significant event record that includes all prescribing information use Read Code to supply monthly data to the Primary Care Trust, facilitation, monitoring and ensuring activity based payment as appropriate carry out the data collection at regular intervals in accordance with the Primary Care Trusts requirements Family Members The medical needs of families of patients who have been subject to immediate removal will need to be considered on a case-by-case basis. Often it is appropriate for them to remain registered with the original practice, which if appropriate will be protected by an injunction from approaches by the removed person on behalf of family members. This injunction would need to be provider led, however support may be sought from the NHS Security Management Service via the Senior Primary Care Commissioning Manager for the locality Under circumstances where a dependent requires care and the dependent needs to be accompanied by the patient who has been removed from the practice list, the DES Provider can treat the dependent as an Immediately Necessary Treatment. If there is a regular requirement for treatment of the dependent, then the Primary Care Trust should consider the most appropriate treatment option RETURN OF PATIENT TO LOCAL PROVIDER The provision of care to a patient within the DES for Violent Patients should be subject to a three monthly review. This should be initiated by the provider of the DES and would give the opportunity to consider whether the patient should continue within the DES. The Provider should invite the patient to a three month review meeting to discuss their progress If it is agreed that the patient has been rehabilitated successfully then the patient should be notified that they can register with their previous Provider or register with a new Provider The Provider should advise the patient to approach practices for registration. If they are unable to register for themselves they will need to be informed of the process of allocation If the Provider decides that the patient should remain with the DES Provider they will be entitled to receive reviews every three months. On an annual basis the patients case should be reconsidered to determine whether further support is required to rehabilitate the patient REVIEW AND AUDIT The Provider shall be subject to an annual review of the Violent Patient Service which will include an audit of: the number of patients using the Violent Patient Service the number of patients leaving the Violent Patient Service where patients have not left the Violent Patient Service, reasons for continuing rehabilitation the number of appointments the number of incidents the number of removals evidence of standards being met The Provider will use the quarterly enhanced services monitoring return to report consultation activity. 6 SIGNIFICANT/ADVERSE EVENTS 6.1 The Department of Health emphasizes the importance of collected incidents nationally to ensure that lessons are learned across the NHS. A proactive approach to the prevention of recurrence is fundamental to making improvements in patient safety. 6.2 The Provider should be aware of the various reporting systems such as: the National Patient Safety Agency National Reporting and Learning System the Medicines and Healthcare products Regulatory Agency reporting systems for adverse reactions to medication (yellow card system), and accidents involving medical devices the legal obligation to report certain incidents to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 6.3 In addition to any regulatory requirements the Primary Care Trust wishes the Provider to use a Significant Event Audit system (agreed with the Primary Care Trust) to facilitate the dissemination of learning, minimising risk and improving patient care and safety. 6.4 In addition to their statutory obligations, the Provider will give notification, within 72 hours of the information becoming known to him/her, of all emergency admissions or deaths of any patient treated by the Provider under this enhanced service, where such admission or death is or may be due to the Providers treatment of the relevant underlying medical condition covered by this specification. Notifications are to be sent to the Director of Nursing and Patient Safety with a copy to the Senior Primary Care Commissioning Manager for the specific locality. 7 PRICING 7.1 In 2008/09, the GP retained to provide the service will receive a retainer fee of 2,178.90 per annum plus a consultation fee of 58 for in-hours consultation. In addition financial support may be provided for infrastructure costs. This is subject to any other local agreement for provision that has been made within a locality area. PAYMENT 8.1 The retainer fee plus an estimated level of consultation fees will be paid in twelfths each month, unless a separate arrangement is agreed with the Trust. 9 PATIENT AND PUBLIC INVOLVEMENT 9.1 The service will conform to professional and legal requirements especially clinical guidelines and standards of good practice issued by the National Institute for Clinical Excellence (NICE) and professional regulatory bodies, and legislation prohibiting discrimination. It is anticipated that for the majority of enhanced services translated information will be available via the Department of Health. If a patient wishes to communicate via a language that is not covered via these leaflets please let the Primary Care Trust Equality and Diversity Lead know and use the commissioned interpretation and translation service (Applied Language Solutions) to facilitate the consultation and provision of information to the patient. Use of the interpretation/translation service should be recorded in the patients lifelong medical record including confirmation of the first language of the patient. 9.2 Practices should encourage, consider and report any patient feedback (positive and negative) on the service that they provide and use it to improve the care provided to patients, particularly if there are plans to alter the way a service is delivered or accessed. 10. REFERENCES 10.1 SOMERSET PRIMARY CARE TRUST (November 2007). Policy for minimising and dealing with violence and aggression in the work environment APPENDIX 1 RISK ASSESSMENT SCORING GUIDELINES Risk Rating Use the tables below to calculate and insert frequency and severity scores on the risk assessment form and consult Risk Matrix belowIf a risk falls in one of the boxes numbered 15 25, immediate action required, so far as is reasonably practicableIf a risk falls in one of the boxes numbered 8 14, prompt action required, so far as is reasonably practicableIf a risk falls in one of the boxes numbered 4 7, risk reduction required, so far as is reasonably practicableIf a risk falls in one of the boxes numbered 1 3, further risk reduction may not be feasible or cost effective Risk Matrix LikelihoodConsequence1 Insignificant2 Minor3 Moderate4 Major5 Catastrophic1 - Rare123452 Unlikely2468103 Possible36912154 Likely481216205 Almost Certain510152025 Frequency (assessment of likelihood of occurrence) 1RareOnly occurs in exceptional circumstances, <1%, 1 5 year strategic risk2 UnlikelyCould occur at some time, 1 5%, at least annually3 PossibleShould occur at some time, 6 20%, at least monthly4 LikelyWill probably occur, 21 50%, at least weekly5Almost CertainExpected to occur, > 50%, at least daily Consequence Modifiers (see table overleaf) Consequence Modifiers (up to a maximum score of 5)ModifiersNumber affectedImportance of Objective/Project/ServicePlus 2More than the whole organisationCritical/Plus 1More than one team or departmentImportant Minus 1Minor Risk Consequence Score 12345DescriptorInsignificantMinorModerateMajorCatastrophic Injury  Minor injury not requiring first aid Minor injury or illness, first aid treatment needed Over three days off sick = RIDDOR reportable. 10 days to report to the HSE  Major injuries, or long term incapacity/disability (loss of limb) Death or major permanent incapacity Patient Experience  Unsatisfactory patient experience not directly related to patient care  Unsatisfactory patient experience readily resolvable Mismanagement of patient care short term effects Mismanagement of patient care long term effects Totally unsatisfactory patient outcome or experience Complaint/Claim Potential Locally resolved complaint Justified complaint peripheral to clinical care Below excess claim. Justified complaint involving lack of appropriate care  Claim above excess level. Multiple justified complaints Multiple claims or single major claim Objectives/Projects Insignificant cost increase/schedule slippage. Barely noticeable reduction in scope or quality  < 5% over budget/schedule slippage. Minor reduction in quality/scope 5 10% over budget/schedule slippage. Reduction in scope or quality requiring client approval  10 25% over budge/schedule slippage. Doesnt meet secondary objectives > 25% over budget/schedule slippage. Doesnt meet primary objectives Service/business interruption  Loss/interruption > 1 hour Loss/interruption > 8 hours Loss/interruption > 1 day Loss/interruption > 1 week  Permanent loss of service or facility Human Resources/Organisational Development Short term low staffing level temporarily reduces service quality (< 1 day)  Ongoing low staffing level reduces service quality Late delivery of key objective/service due to lack of staff (recruitment, retention or sickness). Minor error due to insufficient training. Ongoing unsafe staffing level  Uncertain delivery of key objective/service due to lack of staff. Serious error due to insufficient raining Non delivery of key objective/service due to lack of staff. Loss of key staff. Very high turnover. Critical error due to insufficient training Financial  Small loss (> 100)  Loss > 1,000 Loss > 10,000 Loss > 100,000 Loss > 1,000,000 Inspection/Audit Minor recommendations. Minor non-compliance with standards Recommendations given. Non-compliance with standards Reduced rating. Challenging recommendations. Non-compliance with core standards Enforcement Action. Low rating. Critical report. Multiple challenging recommendations. Major non-compliance with core standards  Prosecution. Zero Rating. Severely critical report Adverse Publicity/Reputation Rumours Loss Media short term Local Media long term National Media < 3 days National Media > 3 days. MP concern (Questions in House) APPENDIX 2 SAMPLE RISK REGISTER AND GUIDANCE 1 CREATING AND MAINTAINING A RISK REGISTER 1.1 Identify any areas where there may be risk to the Provider or a patient. 1.2 Complete risk assessment using the form and guidelines supplied to calculate the risk involved. 1.3 Complete the register by: column A - assign a reference number to the issue column B and C - select the appropriate theme(s) from the suggested list (along with the associated HCC standards) column D - complete brief overarching statement of the risk column E - itemise the areas of concern and any existing control measures (can use sections 2 and 3 from risk assessment form) column F - consequence scoring (can use section 4 from the risk assessment form) column G - likelihood scoring (can use section 4 from the risk assessment form) column H - should automatically calculate ( F x G) column I - controls planned to reduce risk (can use section 5 from risk assessment form) column J - revised risk score should be calculated based on the new control measures put in place column K - identify nominated Provider lead who will review the assessment/register regularly/ensure actions are carried out as required column L - confirm date of planned review colour code columns H and J dependent on the assessment of severity via the Risk Assessment Scoring Guidelines 1.4 Submit a copy of the risk register to your locality Senior Primary Care Commissioning Manager on an annual basis, more frequent submissions (quarterly) may be useful if a severe incident occurs and requires Primary Care Trust support. 2 SAMPLE RISK REGISTER ABCDEFGHIJKLRefStandards for Better HealthThemeStatement of RiskRisk Assessment (Current)ConsequenceLikelihoodRisk Rating Action planned to introduce controlsRetained Risk RatingPractice Lead Date for designated reviewPrimary Care DevelopmentVP ?C1(a), C7(c), C20(a), C21Estates0C1(a), C7(c), C20(a), C21Health and Safety0C5, C8(b), C11Workforce0C7(c), C7(d), C16Information Governance0C1, C4, C7, C8, C11Serious Untoward Incidents0C1, C4, C7, C8, C11Medicines Management0C1, C4, C7, C8, C11Management of Clinical Care0  See reference 10.1.  Orange book with regard to these services is available at  HYPERLINK "http://www.somersetpct.nhs.uk/how%20we%20do%20things" www.somersetpct.nhs.uk/how we do things PINs for accessing this service have been given to each provider.      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