ࡱ>  rSbjbj q<hh I9,I^D87t  !!4#4#4#'4##"4#4#4#!!.)))4#!!)4#))`t!`EnN4#ԘZ|բ<.ɧ$ɧDɧ$X4#4#)4#4#4#4#4#&4#4#4#4#4#4#4#ɧ4#4#4#4#4#4#4#4#4# :  PRIMARY CARE DEVELOPMENT 4.3.3 ENHANCED SERVICE SPECIFICATION FOR CONTRACEPTIVE DEVICES SERVICE OUTLINE 1.1 This service provides for the fitting, monitoring and removal of specific contraceptive devices. 1.2 Intrauterine Contraceptive Devices (IUCDs) and Levonorgestrel Intrauterine System (LNG-IUS) are clinically effective for contraception (failure rate of 0.2-2 per 100 woman-years, lower for the LNG-IUS) and the LNG-IUS has additional benefits regarding the management of menorrhagia (recommended by the Royal College of Obstetricians and Gynaecologists (RCOG)). 1.3 Competence of the professional inserting the device is paramount to reduce failure rates and the possibility of litigation. 1.4 The service should be provided to afford the patient dignity and respect. 2 SERVICE AIMS 2.1 This service aims to ensure that the full range of contraceptive options is provided to patients via their registered provider. 2.2 Provision of post-coital IUCD fitting for emergency contraception, reducing numbers of unwanted pregnancies. Where the accredited General Practitioner (GP) is not available it may be appropriate to onward refer to the Contraceptive and Sexual Health Service run by the Primary Care Trust Provider Services directorate. 2.3 To increase availability of LNG-IUS in the management of menorrhagia within primary care in line with current accepted clinical care of this condition. The Contraceptive and Sexual Health Service will fit for non-contraceptive reasons but only if the GP has provided the prescription. 2.4 Removal of fitted contraceptive devices. 3 SERVICE REQUIREMENTS 3.1 The Provider shall ensure that the Contraceptive Device Service includes, but is not limited to: Service specification and criteria discussing all the different methods of contraception, enabling the patient to make the choice of their preferred method providing written information to patients at the time of counselling and after fitting with information on follow-up and those symptoms that require urgent assessment. The information should take into consideration individual needs and include efficacy, duration of use, possible risks/side-effects, other benefits and when to seek help while using the method. The Family Planning Association IUD/IUS recommended leaflets should be used the fitting, monitoring, checking and removal of Contraceptive Devices as appropriate Fraser guidelines should be followed when providing contraception for women younger than 16 years the issue of condoms to patients to prevent infection (condoms for under 18s supplied and funded by the Primary Care Trust via the Health Promotion Resources Team in Chard) utilising the special equipment that is required for IUCD fitting which includes the use of an appropriate room fitted with a couch and with adequate space and equipment for resuscitation, vaginal specula and cervical dilators ensuring that infection control policies and procedures are in place in accordance with national guidelines with appropriate methods for decontamination and Hepatitis B conversion. Please see Section 4 for more details screening Patients for Chlamydia before insertion of the IUCDs and, if positive, referring the patient for screening for other Sexually Transmitted Infections (STIs) in accordance with national policy carrying out assessments of patients between four to six weeks after fitting the IUCDs where deemed necessary by the performing clinician. Routine annual checks of IUDs or IUS are no longer recommended.,, Women must be advised to return at any time if they have a problem and should be provided with written information. Any problems such as abnormal bleeding or pain should be assessed urgently assessing any problems such as abnormal bleeding or pain after contraceptive devices fitting urgently using LNG-IUS for the management of menorrhagia in primary care as part of a care pathway agreed and developed with local gynaecology departments. These may include other investigations and examinations such as ultrasound/biopsy/hysteroscopy. LNG-IUS should be considered where no structural or histological abnormality is present, or for fibroids less than 3 cm in diameter which are causing no distortion of the uterine cavity. The patient should be clearly informed that this is a hormonal contraception product in case she wishes to conceive anti-epileptic medication should be available at the time of IUD or IUS insertion in a patient with epilepsy 4 HEALTH RECORD 4.1 The Provider is responsible for developing and maintaining an up-to-date register of all patients fitted with a contraceptive device. This will include all patient details, the date of the fitting, information given regarding contraceptive methods and the dates for review. This is to be used for audit purposes, and to enable the primary care team to target these patients for health care screening. Where a patient fitted with a device is not registered with the Provider this information should be clearly documented to facilitate ease of extraction; and developing and maintaining appropriate and accurate records of patients using this service, which includes records of the results of any Chlamydia screening, the pelvic examination, problems with insertion, the type and batch number of the device, and follow-up arrangements 5 CONSENT 5.1 In each case the patient should be fully informed of the treatment options and the treatment proposed. 5.2 National guidelines suggest that written consent should be obtained from patients. The Primary Care Trust wishes the providers to note that their interpretation of written consent in this context is the recording of consent by Read Code. Where the provider Read Codes consent given, the Primary Care Trust will take this to mean that the patient has been fully informed of the treatment options and the treatment proposed, has been offered written information and has given consent. 5.3 The Primary Care Trust would expect that there would be exceptions to this interpretation in certain circumstances (for example if a patient was not competent or appeared uncertain or is under 16 years of age), where actual written consent would be required. It would be for the individual clinician to make the judgement as to what would be deemed necessary. Please refer to the Somerset Primary Care Trust Policy for Consent to Examination of Treatment for further guidance/consent forms if needed. 5.4 The General Medical Council (GMC) have also recently issued a document on consent. These state that the records made should include the information discussed, any specific requests by the patient, any written visual or audit information given to the patient, and details of any decisions that were made and details further guidance regarding the legal framework for capacity issues. 6 TRAINING/ACCREDITATION 6.1 All practitioners undertaking this procedure should make themselves familiar with the processes discussed in Section 3.1 and have undertaken training and updates as detailed in Sections 6.3 and 6.4. Evidence of this training and any updates should be available as part of the annual review where requested. 6.2 All practitioners should have undergone accredited training for this procedure and are responsible for ensuring that their skills are updated regularly to ensure competence is maintained. For IUCD/IUS fitting each practitioner should hold a letter of competence in intrauterine techniques and undertake a minimum of twelve IUCD fittings per annum (of at least two different devices) along with a minimum of two hours education in five years. Where smaller registered populations make this difficult advice and agreement from the Primary Care Trust should be sought in order to continue providing this service. 6.3 For Implanon insertion and removal all practitioners should have undergone accredited training for this procedure and are responsible for ensuring that their skills are updated regularly to ensure competence is maintained. Practitioners should hold either a letter of competence for sub-dermal implants or Royal College of Nursing (RCN) Accreditation for the insertion/removal of sub-dermal implants. A minimum of six implants should be fitted per annum (to include both insertion and removal) and evidence of two hours education relating to implants in five years/re-certification in line with the Faculty of Sexual Health and Reproductive Healthcare/RCN training guidance available. Please complete and return the form at Appendix 1 regarding the individual practitioners providing this service. Accreditation 6.4 Evidence of Continuing Professional Development (CPD) and training should be maintained by the provider and may be reviewed as part of the General Practitioner (GP) appraisal process or separately to confirm accreditation for this service. 6.5 National guidance on premises standards must be adhered to. 7 INFECTION CONTROL 7.1 Providers must have infection control policies that are compliant with national guidelines, which include: disposal of clinical waste needle stick incidents environmental cleanliness standard precautions, including hand washing 8 REVIEW AND AUDIT 8.1 The Provider shall carry out an annual review of the contraceptive devices service which will include an audit of: the register of patients fitted with the contraceptive device the number of patients fitted with a device where a discussion regarding choice of method and information has been provided to the patient is recorded continuous usage rates failure rates reasons for removal, and complications/adverse incidents 9 SIGNIFICANT/ADVERSE EVENTS 9.1 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. 9.2 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, and the legal obligation to report certain incidents to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). 9.3 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. 9.4 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. 9.5 Incidence of Methicillin-Resistant Staphylococcus Aureus (MRSA) and/or Clostridium difficile infection post the fitting of the device should be regarded as an adverse incident and as such be reported to the Primary Care Trust Infection Control Team and the individual clinician who fitted the device. 10 PRICING 10.1 In 2008/09 Providers providing this service will receive 90.07 insertion fee per patient (for IUCDs and (Implanon). This fee will only be payable where the Provider is using single use instruments. Providers using Sterile Services from an acute or Foundation trust are no longer eligible to receive payment under this enhanced service. 10.2 As routine annual reviews are not recommended Providers will be paid a lump sum to cover the cost of patients who do return due to problems with the fitting. This lump sum will be paid on the basis of one third of the number of registered patients with a Provider fitted contraceptive device multiplied by 21.23. 11 PAYMENT 11.1 Payment will be made to the Provider on a monthly basis, the budget will be set on the outturn level of activity plus the number of patients with devices in situ as at 1 April of the current financial year. 11.2 Payments will be reconciled after the end of the financial year on the basis of actual numbers of fittings completed. 12 PATIENT AND PUBLIC INVOLVEMENT 12.1 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. 12.2 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. 13 REFERENCES 13.1 NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE). (2005) Clinical Guideline 30: Long-acting reversible contraception. Report published October 2005. Available at  HYPERLINK "http://www.nice.org.uk/nicemedia/pdf/cg030niceguideline.pdf" www.nice.org.uk/nicemedia/pdf/cg030niceguideline.pdf 13.2 FAMILY PLANNING ASSOCIATION (FPA). (2007) Your guide to the IUD. Leaflet published October 2007. ISBN: 1905506325. Available at  HYPERLINK "http://www.fpa.org.uk/attachments/published/152/PDF IUD October 2007.pdf" www.fpa.org.uk/attachments/published/152/PDF IUD October 2007.pdf. Leaflets can be obtained from the Primary Care Trust Health Promotion Resources team in Chard. 13.3 FAMILY PLANNING ASSOCIATION (FPA). (2007) Your guide to the IUS. Leaflet published October 2007. ISBN: 1905506317. Available at  HYPERLINK "http://www.fpa.org.uk/attachments/published/154/PDF IUS October 2007.pdf" www.fpa.org.uk/attachments/published/154/PDF IUS October 2007.pdf Leaflets can be obtained from the Primary Care Trust Health Promotion Resources team in Chard. 13.4 FACULTY OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE (FFPRHC). 2004. FFPRHC Guidance: The Copper Intrauterine Device as long term contraception. The Journal of Family Planning and Reproductive Health Care. 30 (1), pp29-41. Available at  HYPERLINK "http://www.ingentaconnect.com/content/ffp/jfp" www.ingentaconnect.com/content/ffp/jfp 13.5 WORLD HEALTH ORGANISATION (WHO). (2004) Selected Practice Recommendations for Contraceptive Use. Report published 2004, Geneva. ISBN: 9241562846. Available at:  HYPERLINK "http://www.who.int/reproductive-health/publications/spr/" www.who.int/reproductive-health/publications/spr/ 13.6 FACULTY OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE (FFPRHC). (2002) UK Selected Practice Recommendations for Contraceptive Use. Available at:  HYPERLINK "http://www.ffprhc.org.uk/admin/uploads/Final%20UK%20recommendations1.pdf" www.ffprhc.org.uk/admin/uploads/Final UK recommendations1.pdf 13.7 NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE). (2007) Clinical Guideline 44: Heavy menstrual bleeding. Report published January 2007. Available at  HYPERLINK "http://www.nice.org.uk/nicemedia/pdf/CG44NICEGuideline.pdf" www.nice.org.uk/nicemedia/pdf/CG44NICEGuideline.pdf 13.8 SOMERSET PRIMARY CARE TRUST. (Unpublished, November 2007) Policy for Consent to Examination or Treatment. Available at  HYPERLINK "nww.somersetpct.nhs.uk/Policies/Policy%20Documents/Clinical%20Practice/CP005%20Vers1.4%20Consent%20Policy.pdf" nww.somersetpct.nhs.uk/Policies/Policy Documents/Clinical Practice/CP005 Vers1.4 Consent Policy.pdf 13.9 GENERAL MEDICAL COUNCIL (GMC). (2008) Consent: patients and doctors making decisions together. Report published 2008. Available at  HYPERLINK "http://www.gmc-uk.org/guidance/ethical_guidance/consent_guidance/" www.gmc-uk.org/guidance/ethical_guidance/consent_guidance/ 13.10 FACULTY OF SEXUAL & REPRODUCTIVE HEALTHCARE OF THE RCOG (FSRH). (2008) LoC SDI and LoC IUT Changes to training requirements and recertification. Paper issued March 2008. Available at  HYPERLINK "http://www.ffprhc.org.uk/admin/uploads/RecertChanges2008doc.pdf" www.ffprhc.org.uk/admin/uploads/RecertChanges2008doc.pdf 13.11 ROYAL COLLEGE OF NURSING (RCN). (2007) Inserting and removing subdermal contraceptive implants: Training guidance for nurses. Published February 2007. Available at  HYPERLINK "http://www.rcn.org.uk/__data/assets/pdf_file/0005/78602/002240.pdf" www.rcn.org.uk/__data/assets/pdf_file/0005/78602/002240.pdf 13.12 NHS ESTATES. (1992) Health building note HBN 46: General medical practice premises for the provision of primary health care services. HMSO: London. ISBN:  HYPERLINK "http://www.tsoshop.co.uk/bookstore.asp?Action=Book&ProductId=0113214030" 9780113214037 13.13 DEPARTMENT OF HEALTH (DH). (2008) The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections. Report published 11 January 2008. Available at  HYPERLINK "http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081927" www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081927 APPENDIX 1 LIST OF NAMED PRACTITIONERS Provider Name: The below named GPs will be providing services under the Contraceptive Device Enhanced Service for patients registered with this provider. The practitioners have all received training as listed in the specification Sections 6.2 and 6.3 and can provide evidence of this as requested. General PractitionerSignatureIUCDImplanonDate             Please indicate if the GP is fitting and removing IUCDs and/or Implanons.  See reference 13.1  See references 13.2 and 13.3.  See reference 13.4.  See reference 13.5.  See reference 13.6.  See reference 13.7.  See reference 13.1.  See reference 13.8.  See reference 13.9.  See reference 13.10.  See reference 13.11.  See reference 13.12.  See reference 13.13.  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