NHS STANDARD CONTRACT

Transcription

1 Service Specification Service / Care pathway Acute Elective Surgery, including pre-operative and post assessment care & Gastroenterology services Commissioner Lead East Cheshire CCG Provider Lead Period 1 st December st October, 2017 Date of Review Annually 1. Purpose 1.1 Aims and Objectives The CCG s wish to commission Acute Elective Surgery. This is to be established via the Any Qualified Provider model. To deliver high quality, value for money Acute Elective Surgery in accordance with Good Clinical Practice in respect of clinical services and in addition, Good Industry Practice in respect of Services other than Clinical Services. To maintain capacity that supports The Commissioner, thus ensuring delivery of the agreed referral to treatment times. To maintain access to a range of Acute Elective Surgeries thereby improving NHS Patients Free choice of Provider and control over their care and treatment. To provide the NHS Patient with the choice of named consultant-led team for elective care where clinically appropriate from 1 st December To ensure the provision of safe and effective Elective Service provision to NHS Patients. To continually improve the quality and value of care for NHS Patients in line with current Good Clinical Practice. To achieve the agreed referral to treat waiting times. To achieve and wherever possible, improve upon Acute Elective Surgery clinical pathways. To maintain levels of capacity of Acute Elective Surgery for NHS Patients. Source: Equity and excellence: Liberating the NHS, Gateway 14385, July

2 1.2 National / local context and evidence base The creation of clinical pathways and specifications will be made where possible against published evidence based documents or systems. Furthermore, The Provider shall undertake the review and update of specifications routinely on an annual basis or sooner if there is a change in regulation or evidence of best practice. Where The Provider wishes to use alternative evidence based pathways or systems these will be submitted to The Commissioner and The Provider shall demonstrate the methodology and provenance of the alternative system. The intention is that The Provider should be able to state their variance to that agreed pathway or system and should provide the supporting evidence for that variation or the rationale in support of the variation. It is the intention of The Commissioner to allow The Provider freedom to introduce innovation but for this to be systematised and measurable. Thus, the focus will be mainly on the differences and not conformity of the norm. Further guidance is contained within this Schedule 2 section 3 Service Delivery Requirements, which The Provider will be expected to fully adhere to. 2. Service Scope 2.1 Service Description This Any Qualified Provider Service Specification promotes NHS Patient choice and aims for Acute Elective Surgeries to be delivered from a range of accredited providers. It identifies specialties which are to be delivered as clinically appropriate under sedation, local anaesthetic and general anaesthetic; and it allows for the associated pre and post-operative services necessary for Good Clinical Practice to be delivered as part of a seamless pathway of NHS Patient care. For clarity, the term Provider within this specification refers to each individual site from which an organisation wishes to provide services and each site must be compliant with the specification and each site will be expected to comply with all aspects of the contract at site level. Specialities to be provided but not limited to are: a. ENT b. Oral Surgery c. General Surgery d. Gynaecology e. Orthopaedics/Musculoskeletal f. Ophthalmology g. Urology h. Gastroenterology including Endoscopy Providers must be able to offer the full patient pathway at Specialty level for Acute Elective Surgery from the first outpatient to completion of treatment. However, Providers will also be required to accept referrals where the NHS Patient has already undergone an assessment and been diagnosed for treatment. 2

3 Facilities from which patients are treated must be appropriately registered by the Care Quality Commission and meet all statutory requirements and be fit for purpose as required under the Care Standards Act 2000, and any other legislation that affects the nature of the accommodation for the type of services to be provided. Providers must be able to offer the full patient pathway for the Elective Care Services from the first outpatient to completion of treatment. However, Providers will also be required to accept referrals where the NHS Patient has already undergone an assessment and been diagnosed for treatment. 2.2 Accessibility/acceptability The aim is to maintain service capacity for NHS Patient communities, whilst ensuring equal access and availability to all suitable NHS Patients requiring Elective Care Services The Provider will ensure that services meet NHS Patient needs for flexibility by providing Services outside of the ordinary operating hours for example, offering care and treatment in the evening and at weekends The Provider will ensure that the service maintains equity of access, by: (i) Not discriminating between NHS Patients regardless of age, sex, ethnicity, religion, disability or any other non-medical characteristic. (ii) Delivering services in a format suitable for differing NHS Patient needs, by implementing Royal National Institute for the Blind and Royal National Institute for the Deaf guidance, and any other relevant guidance to ensure NHS Patients who have disabilities and/or communications difficulties are able to receive the Services. (iii) Delivering at no cost (to Commissioner/NHS Patient), professional translation services and translations of materials available to NHS Patients describing relevant procedures for the commonest ethnic languages of NHS Patients most likely to use the Services as recommended by The Commissioner or their agent The Provider will ensure that they comply with the NHS Standards for Privacy, Dignity and Respect. 2.3 Exclusion Criteria There should be no discrimination on the grounds of age, sexuality, gender, ethnicity or disability except for the following agreed exclusions NHS Patient Exclusion Group: The Provider may reject any referred NHS Patient during any period where: a. The physical status of the Referred NHS Patient is not ASA1, ASA2, or ASA3 (stable) where the procedure is to be undertaken with general anaesthetic, save where the NHS Patient will not require general anaesthetic, or where clinical judgement suggests it is not in the patient s best interests to treat on clinical grounds. b. the NHS Patient has a Body Mass Index of more than Forty (40) c. The NHS Patient is under the age of eighteen (18). d. At any time from the Receipt Date until two (2) Business Days prior to the date of the First Out Patient Appointment, if The Provider becomes aware that an NHS Patient falls within any of the circumstances set out above The Provider may, acting in accordance with Good Clinical Practice, reject the Referral of such NHS Patient. Rejection of Referrals: The Provider shall not reject a Referral unless: a. The NHS Patient is an excluded NHS Patient. 3

4 b. The procedure falls within the Procedure Exclusion Group. Where The Provider rejects a Referral, for the reasons set out, The Provider shall within two (2) Business Days of becoming aware of the circumstances, refer the NHS Patient back to the relevant Referring Clinician (or NHS Patient s GP if different) giving details of the reasons for rejection and record such reasons in the NHS Patient s records. Procedure Exclusion Group: The following procedure groups are excluded from this Agreement: a. Clinically urgent procedures (being NHS Patients that require surgery within 10 days for a clinical reason). b. Procedures related to the treatment of malignant diseases. c. Procedures related to transplant surgery. d. Procedures related to maternity services. e. Termination of pregnancy. f. Surgery indicated to be for cosmetic reasons. g. Any procedure that is likely to require critical care, unless the appropriate critical care facilities that meet the Levels of Critical Care for Adult Patients Standards and Guidelines (Intensive Care Society 2009) are available h. In vitro fertilisation treatment for a NHS Patient. i. The procedure is one of those highlighted within the current (and future) Prior Approval Policies which includes procedures of lower clinical priority and thresholds for other procedures as published by The Commissioner. j. Any procedure or treatment which falls outside the scope of Cheshire and Merseyside s Any Qualified Provider accreditation Unsuitability: If The Provider determines in accordance with Good Clinical Practice that the activity for which the NHS Patient has been Referred is: a. Not required in the opinion of the Healthcare Professional assessing the NHS Patient. b. Not within the scope of the Services of The Provider under this Agreement. The Provider shall refer the NHS Patient back to the Referring Clinician with an explanation of why the NHS Patient is not suitable for treatment by The Provider. 2.4 Geographic coverage / boundaries The population to be covered should include all patients registered with a GP practice for which the host commissioner or any of its associates is the responsible commissioner. Patients outside of this may be seen, and invoiced under NCA arrangements. 2.5 Whole System Relationships The level of responsibility of the stakeholders for the NHS Patient will change as the NHS Patient moves through the care pathway. Initially, The GP will have a higher level of responsibility to ensure NHS Patients enter the care pathway. This responsibility will change at the point of entry into The Providers care pathway thereafter The Provider will take the majority of responsibility for the NHS Patient s care until final discharge occurs at the post-operative follow up assessment. The Provider will be expected to maintain an appropriate set of clinical protocols and guidelines to support the operational management of the Service, which The Commissioner will have access to and agreement on 4

5 content. These should be reviewed on an annual basis or as required in line with the development of best practice. The clinical protocols and guidelines should include all services which will be provided to The Provider and by The Provider. These should specify the services and NHS Patient pathways that could be used if the need arises, including referral on, with responsible persons and contact numbers, in order that all parties in the pathway, are aware of the arrangements that are made for: a. Access criteria including The Commissioner s Prior Approval Policy. b. Care pathways. c. Transferring of acutely ill NHS Patients, including clinical emergencies. d. Discharge arrangements. e. Requests to follow up NHS Patients. f. Estates management. g. Complaints procedures. NHS referred patient should not be asked to provide credit card details, unless the patient has requested additional hotel facilities provided for patients by the provider, which will be charged to the patient on a cost per use basis in the medium that the patient chooses. 2.6 Interdependencies with other services The Provider will be required to co-operate effectively with other relevant providers in the local health economy to provide seamless care for patients including but not limited to participating CCG s, community healthcare providers, social services, Acute Trusts and local GP s. Providers will be required to treat patients in accordance with Referral to Treatment Standards, and any additional waiting time targets set out in the NHS Operating framework The Referrer will: (i) (ii) The Commissioner or Patient s GP may refer any NHS Patient to The Provider s facility for the provision of Clinical Services, in line with the Terms and Conditions of this Contract. Access booking slots in order to book the NHS Patient s initial appointment The Provider will: (i) (ii) (iii) (iv) (v) (vi) Maintain appropriate information systems, which are compliant with NHS IT requirement, including N3 connection and NHS Net. Provide the NHS Patient with information as necessary to assist the NHS Patient in understanding their proposed care and if necessary, information with respect to transport arrangements to and from the site. At all stages of the pathway inform The Referrer about the progress of NHS Patients through the system and if required liaise with The Commissioner with respect to any capacity planning that is required. Following surgery, (where necessary) arrange via liaison with NHS Community Services, appropriate community support, including district nursing. At the final follow up assessment, ensure that NHS Patients have in place an agreed care pathway. Once final discharge has occurred responsibility for the NHS Patient s care falls to the GP. The Provider will provide information about travel and reimburse according to the Hospital Travel Costs Scheme. 5

6 (vii) (viii) The Provider shall administer all statutory benefits relevant to the provision of the Services which NHS Patients may be entitled to and in addition, administer and collect all statutory charges which may lawfully be made in relation to the provision of the Services. The Provider shall comply with the higher standards of i) the NMS standards and ii) the highest available CNST Standard in relation to medicine management, available from time to time. If The Provider s Staff use NHS prescription forms (for dispensing in the community), The Provider shall ensure appropriate security arrangements are developed and maintained. 2.7 Relevant networks and screening programmes Please refer to the Commissioner s CLINICAL NETWORKS AND SCREENING PROGRAMMES. 2.8 Training / education / research activities Ensure that sufficient Staff with appropriate skill, training and competence are available to maintain patient safety at all times when patients are in the Facility. The Provider is required to comply with the relevant statutory bodies and competent authorities responsible for registration and monitoring of clinical activities. The Provider will only be able to offer Acute Elective Surgery and any subsequent re-admissions relating to the original treatment or procedure that fall within the scope of services within their CQC registration & Any Qualified Provider accreditation for a particular facility. The Provider is expected to adhere to NICE Quality Standards to ensure Patients understand what service they can expect from their health provider, and Commissioners have assurance that the services they are commissioning are high quality and cost effective. The Provider is expected to be compliant with relevant NICE Technology Appraisals (TAG s) where this is agreed and funded as part of the National tariff. This includes TAGS covering:- medicines medical devices (for example, hearing aids or inhalers) diagnostic techniques (tests used to identify diseases) surgical procedures (for example, repairing hernias) health promotion activities (for example, ways of helping people with diabetes manage their condition). The Provider will be expected to comply with the recommendations contained within relevant NICE Clinical Guidelines where treatment is part of an NHS PbR tariff as NICE and the Department of Health's tariff setting team identify the impact of guidance and adjust the tariff accordingly. For NICE non PbR activity the Provider and commissioner will need to calculate the financial implications, and agree changes to service level agreements or contracts where necessary. 2.9 Sub-contractors The Provider shall not sub-contract any activity without the previous consent in writing of The Commissioner If consent to sub-contract is requested The Commissioner may insist upon the production to it (inter alia) of all responsible information and documentation relevant to the financial liability, competence and relevant experience of the proposed sub-contractor If consent to sub-contract is requested The Commissioner may insist upon the production to it (inter 6

7 alia) of proof of appropriate and adequate insurance in place for the life of the sub-contract The sub-contractor will be bound by the same terms and conditions of the primary contractor. 7

8 3. Service Delivery 3.1 Service model The Provider must be able to offer the full patient pathway for Acute Elective Surgeries from the first outpatient appointment to completion of treatment. However Providers will also be required to accept referrals where the NHS Patient has already undergone an assessment and been diagnosed for treatment. Under such circumstances, The Provider should continue with the agreed pathway for these referrals accepting the results of any prior diagnosis/assessment and testing, in order to prevent unnecessary duplication of said procedures. Under such circumstances, The Provider will be expected to demonstrate that any duplication of said procedures was clinically necessary. The clinical objectives are for The Provider to deliver high quality clinical services, that: a. Help People to Stay Healthy b. Empower Patients c. Provide the Most Effective Treatments; and d. Keep Patients as Safe as Possible The service should be delivered in accordance with the guiding principles of the NHS, to provide a comprehensive service, available to all, free at the point of care, based upon need not ability to pay. The service should: a. Put patients at the heart of everything that the NHS does. b. Focus on continually improving the things that really matter to Patients the outcome of their healthcare; and Empower and liberate clinicians to innovate with the freedom to focus on improving healthcare services. c. The Provider is expected to adhere to NICE Quality Standards and Guidelines at all times. d. Further information on current best practice guidelines, are available at: e. The Provider will be expected to comply in all respects with the following standards and recommendations, and successive documents, as best practice develops: f. The Code of Practice for the International Recruitment of Healthcare Professionals (December 2004) applicable for overseas recruitment: g. Developing medical regulation: A vision for the future. Proposals for the licensing and revalidation of doctors in GMC publication. h. Independent Healthcare National Minimum Standards i. Complaints Legislation: The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (opens new window) The Local Authority Social Services and National Health Service Complaints (England) (Amendment) Regulations 2009 (opens new window) j. NHS Core Principles k. NHS Constitution l. Maintaining High Professional Standards in the Modern NHS, Department of Health HSC 2003/012, updated in

9 m. The Royal College(s) and professional bodies published guidelines for the associated healthcare professionals involved in the delivery of Elective Care Services, including, but not limited to: The Royal College of Surgeons The Royal College of Anaesthetists The Royal College of Obstetricians and Gynaecologists The Royal College of Nursing The Royal College of Radiologists The Chartered Society of Physiotherapy The Health Professions Council n. Safer Recruitment A Guide for NHS Employers (April 2006) Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A strategy for NHS trusts: a summary of best practice. Department of Health The Provider is required to operate robust clinical governance processes and procedures to ensure that services are delivered in accordance with Good Clinical Practice. The Provider must demonstrate that clear lines of medical, clinical, and managerial accountability operate at a corporate and facility level. The Provider will be expected to deal with clinical emergencies safely and effectively, with access to specialist trained staff supported by suitable equipment and emergency drugs in compliance with the Resuscitation Council (UK) Critical Care Guidelines (and local Critical Care Network Guidelines). Source: Equality and Excellence: Liberating the NHS, DH Gateway ref: 14385, July Expected Outcomes The Provider will provide a quality service which delivers better patient outcomes: The NHS Patient will experience a measurable improvement in their clinical condition or resolution of their pre-operative symptoms, as measured by clinical outcomes measures. Whilst undergoing treatment, the NHS Patient will benefit from high quality Patient centred care, resulting in a positive Patient experience and measurable high satisfaction with the care that they receive. Levels of Elective Care Services provision are maintained across the North West. NHS Patient choice is enhanced through the introduction of Any Qualified Provider. The delivery of the service will remain within agreed budgetary parameters. Appropriate case mix and quality and performance standards are achieved as stipulated within Schedule 2, - the Quality, Clinical Outcomes and User/Carer Satisfaction requirements of this Agreement. NHS Patients will benefit from the choice of named consultant-led team for elective care where clinically appropriate. Where in line with Good Clinical Practice and where the NHS Patient s general health allows, Day Case (as opposed to Inpatient surgery) is performed. The Provider is required to deliver Acute Elective Surgeries in accordance with the Health and Social Care (Community Health Standards) Act 2003, the NHS Standard Contract; the NHS Operating Framework; Good Clinical Practice, Good Industry Practice and Good Health and Social care Practice and in such a way as to meet 9

10 National and Quality Standards. Providers will be required to comply with any changes in standards and legislation as set out in the NHS Standard Contract. 3.3 Equipment and Consumables Equipment and consumables may be purchased via the NHS Supply Chain contracts or via alternative suppliers providing that they are to the same specification and CE marked. The Provider will be responsible for ensuring compliance prior to purchasing Equipment and Consumables must be in current production and where applicable, there will be a service agreement from the distributor/manufacturer in force at times. 3.4 Care Pathways Please see Error! Reference source not found. for details of the main organisations involved or linked to the provision of the service. 3.5 Location(s) of service delivery The Provider will be responsible for all costs associated with setting up the Elective Care Service and the provision of the service. TBC 3.6 Days / Hours of operation The provider will be expected to operate a safe service Monday to Sunday, 24 hours per day. The service should have the capacity to meet the demand according to indicative activity case mix agreed at contract award. 3.7 Referral criteria and sources The Commissioner or Patient s GP may refer any NHS Patient to The Provider s facility for the provision of Clinical Services, in line with the Terms and Conditions of the NHS Standard Contract. The Provider will be expected to provide the Clinical Services in a manner consistent with the NHS Constitution. Where The Provider determines that the NHS Patient is not suitable for receiving treatment in The Provider s facility, The Provider, acting in accordance with Good Clinical Practice shall: a. Refer the NHS Patient back to the Referring Clinician if the proposed intervention is: 1. Not required in the opinion of the Healthcare professional assessing the NHS Patient; or 2. Not within the scope of the Services to be provided by The Provider in accordance of the Agreement. 3. Within one of the exemptions listed within 4.6 of this specification, which includes but is not limited to the following: i. An Excluded NHS Patient ii. An Excluded Procedure iii. The Referring Clinician is not approved under the scheme referral protocol. b. Following receipt of permission of The Commissioner: Where at any point in the care pathway The Provider determines in accordance with Good Clinical Practice that the NHS Patient is not fit for surgery anywhere, The Provider s obligation to comply with the Referral to Treat Waiting Times shall cease in respect of that NHS Patient and activity, upon The Provider referring the NHS Patient back to the NHS Patient s GP and/or Referring Clinician (if different) with an explanation of why 10

11 the NHS Patient is not fit for surgery anywhere. The Referral to Treat Waiting Times continues if The Patient still requires surgery but needs this doing elsewhere. 3.8 Referral process The Provider shall accept Referrals through: a. The web-based interactive system, Choose and Book. b. Inter Provider Transfers from other NHS Providers of healthcare. c. Written referrals from approved referral sources. The information will comply with national guidance on NHS Patient data requirements and the disclosure of such data. The following information will be made available to The Provider for each NHS Patient referred into the service: a. Clinical Minimum Data Set: 1. Presenting complaint 2. Pertinent clinical information including indications, pertinent history, results of any diagnostic investigations and provisional diagnosis if available. 3. Current symptoms including duration. 4. Details of any previous treatment including medications given to the NHS Patient for the condition. 5. Relevant past medical history. 6. Details of current medications and any other known allergies (e.g. allergies to intravenous contrast). 7. Details of any matter which the Referrer considers could affect the nature of the Service provided including social and local authority services. 8. Any special needs (e.g. interpreter required, disabilities requiring special handling, carer support). 9. Body Mass Index b. Administrative Minimum Data Set: 1. Basic contact information for the NHS Patient including: full name (and title), sex, NHS Number, date of birth, address and postcode, home and daytime telephone number, evening telephone number. 2. Name, address, and telephone number of the Referring Clinician and any other Health Professionals who are to receive copies of the Discharge Summary. 3. Date of referral. 4. Any relevant factors influencing the NHS Patient s ability to receive and respond to communications including without limitation lack of fluency in English, visual or auditory impairments, etc. c. Information appreciated at point of referral if known: 1. Ethnicity. 2. Mobile telephone number for patient and address. 3. Marital Status. 4. Blood pressure reading. 5. Referral PCT code, Referring Clinician practice code. 6. Name, address and telephone number of the patients next of kin. 7. Marital or civil partnership status. 3.9 Medical Onward Referrals from or within Provider s Services A complication or variance to care pathway could necessitate an onward referral at any point of 11

12 the NHS Patient s journey. However, The Provider will still be expected to act in accordance with The Commissioner s Consultant to Consultant Referral Policy The decision to make an onward referral will depend on the severity or urgency of such a Referral Such urgent referrals would include medical and surgical complications These referrals would include emergency transfers to an Acute Trust of an unstable NHS Patient Also included would be transfers to a non-provider facility for investigation or treatment which cannot be provided by The Provider (i.e. VQ scan for PE) An onward referral might necessitate the NHS Patient remaining at a non-provider facility for remainder of treatment or returning to The Provider once stable or diagnosis confirmed Onward referral would also occur if a serious medical complication is discovered by The Provider either directly as part of the procedure or on examination Such onward urgent referral may be made within The Provider s facility, if appropriate staff and facilities are available e.g. to Physician or Specialist for medical opinion, subject to prior authorisation of the referral by The Commissioner and NHS Patient choice If specialism is not available at The Provider s facility, The Provider s Consultant will refer externally to appropriate facility Any onward referrals will be fully communicated immediately to Referring GP and The Commissioner by The Provider Consultant with full report of findings and reasons for referral If an onward referral is not urgent and needs longer term treatment and supervision by GP, Provider Consultant will write to Referring GP recommending such a referral to be made via the GP. 4 Onward Referral for Cancer Treatment 4.1 Onward referral will occur if significant pathology is discovered or suspected by The Provider as part of procedure or on examination. The Provider will act in accordance with the Cancer network guidelines and National Cancer Waiting Time Standards. 4.2 This referral will be from The Provider Consultant to receiving approved Specialist Consultant. 4.3 The Provider will be expected to establish with The Commissioner appropriate onward referral pathways in relation to significant pathology. 4.4 The Provider will be expected to follow a policy similar to the Management of an Unsuspected Diagnosis of Cancer guidance, as designated by The Commissioner. 4.5 Any onward referrals will be fully communicated immediately to Referring GP and The Commissioner by The Provider Consultant with full report of findings and reasons for referral. 5 Onward Referral to Community Nursing or Therapies 5.1 SLAs will be in place to ensure continuity of care into the community for NHS Patients who need follow up care and assessment once discharge home from The Provider s facility. 5.2 Alternatively The Provider will directly provide this care at home as part of the care pathway. 5.3 This care will include post-operative wound care, mobilisation and rehabilitation as appropriate to procedure performed. 5.4 There will be clear referral protocols and procedures from The Provider to community services. 5.5 There will be clear access routes for community services to contact The Provider 24 hours per day for advice, referral back to The Provider and updating of NHS Patient record. 5.6 Any unplanned complications post discharge, directly related to procedure, will be referred back to The Provider for management and not to referring GP. 5.7 If review by Consultant or re-admission to The Provider is required, this will be arranged by The Provider. 5.8 The Tracker will be updated accordingly and reported to the Referring GP and The Commissioner. 5.9 If care in the community follows predicted care pathway and recovery is satisfactory, the community services will confirm this in writing and send report to The Provider. 12

13 5.10 This will conclude episode of care if no further follow up appointments are required This will be recorded in the NHS Patient record and a summary sent to Responsible Consultant, Referring GP and The Commissioner This closure of episode of care will be entered on Tracker. 6 Discharge Communication 6.1 The Provider will provide the NHS Patient s GP with appropriate discharge information as set out in the NHS Standard Acute Contract. 6.2 NHS Patients must be discharged into a safe environment, in accordance with Good Clinical Practice and Good Health and Social Care Practice. This might include The Provider arranging for social care, domiciliary/district nursing services to be available on discharge and a care transfer plan being agreed between the third party and the NHS Patient and any carer. The Commissioner will provide a list of appropriate contacts to be used in this event (which will be reviewed annually by The Commissioner). 7 Self-Care and Patient and Carer Information 7.1 The Provider s contact with the NHS Patient starts at the point the NHS Patient is referred by the NHS Patient s GP. The Provider will produce all necessary Information which must be the NHS Patient s GP. The Provider will produce all necessary Information which must be given to each NHS Patient at the time the initial appointment is confirmed in writing and at appropriate points in the care pathway. 7.2 The content of the information will be in line with the appropriate guidelines and explains in layman s terms all aspects of the NHS Patient s journey including complication rates and how to obtain help if it is needed. The Provider will also ensure that NHS Patient information can be accessed via their website and/or via a NHS Patient information DVD. 7.3 The Provider will establish a helpline that will assist NHS Patients in gaining more information about their procedure and that can provide advice post procedure. 7.4 The NHS Patient will be given written and verbal instructions supporting appropriate self- management. 7.5 The NHS Patient will be given a copy of their discharge letter from the service. 8 Quality Requirement 8.1 The Provider will be expected to participate in Regional, National and International Clinical Audits relevant to the particular specialty and anaesthetics and report back outcomes to The Commissioner. 9 Provision of Information 9.1 At least five (5) Business Days prior to the First Out Patient Appointment The Provider shall ensure that the NHS Patient is provided with verbal and written information to: (i) Confirm the time and exact location of the First Out Patient Appointment as previously notified to the NHS Patient. (ii) Explain how to prepare physically, mentally and socially for the activity, including potential late complications and how to seek help if they occur. (iii) Provide appropriate advice regarding their fitness to drive or use public transport following the activity. (iv) (v) Explain the activity procedure/process. Outline any preparation the NHS Patient should make before attending the Facility, including but not limited to: a. Suitable attire. b. Special instructions (e.g. fasting, full bladder, etc); and c. Not to bring valuables to the Facility. 13

14 (vi) (vii) Confirm the location of the Facility, and Provide directions to the Facility (including details of car parking and public transport. 10 Steps At First Out Patient Appointment Where Appointment Where Required By Referral Pathway 10.1 Each Provider will be required to agree with The Commissioner an Access Policy that outlines the standards for managing NHS Patient access to the Elective Care Services for NHS patients from referral to treatment, and discharge to primary care. The Access Policy should be published on The Provider web site At the First Out Patient Appointment The Provider shall: (i) Obtain any relevant information about the NHS Patient which is additional to the NHS Patient Referral Information by means of any or all normally accepted professional activities including interview, clinical examination, fitness assessment, diagnostic imaging and pathology, in order to: a. Make or confirm a diagnosis; and/or b. Where relevant assess the NHS Patient s fitness for surgery, including as appropriate an anaesthetic assessment, nursing assessment, physiotherapy assessment, and a discussion based assessment of the NHS Patient s needs anticipated home care needs and modifications (referring such NHS Patient needs to appropriate social services or primary care services)(as applicable) and social circumstances; and/or c. Determine the treatment option which it considers is the most appropriate for the NHS Patient. (ii) Inform the NHS Patient as to the diagnosis and any other significant clinical findings of which The Provider may be aware as a result of The Provider s assessment of the NHS Patient in accordance with paragraph 10.2 (i) of this pathway. (iii) Discuss with the NHS Patient the risks, benefits and Care Pathway relating to all appropriate treatment. The key elements of the Care Pathway for this purpose may include: a. Risks and benefits of the procedure. b. Different procedure options. c. The choice of prosthesis or walking or living aids where relevant. d. The choice of anaesthetic, if appropriate. e. Pain management options. f. Where clinical or other factors override the NHS Patient receiving treatment on a Day Case basis or as an Out Patient, whether (where a choice is available) the admission will be as an In Patient. g. Anticipated length of stay; and h. Rehabilitation and estimated time for recovery. (iv) Discuss with the NHS Patient the risks, benefits and rationale for any onward referral for alternative or additional advice, tests, investigations or treatments which in the assessing Healthcare Professional s opinion is required. (v) Ensure that the NHS Patient has sufficient time to consider the information being given to them by The Provider and the opportunity to discuss this with their choice of next of kin, carer, or other persons of the NHS Patient s choice. (vi) Obtain informed consent to surgery or invasive investigations from the NHS Patient in accordance with current legislation and best practice guidelines. (vii) Obtain consent from the NHS Patient in accordance with current legislation and best practice guidelines, in relation to: a. The use of the NHS Patient s medical records. b. Medical photography. 14

15 (viii) (ix) (x) (xi) c. Involvement of teaching or training; and d. The Information Sharing Protocol. Advise the NHS Patient of any preparation for surgery which may be required or is desirable, such as exercises to strengthen muscles, smoking cessation or losing weight. Prepare a plan for the Discharge of each NHS Patient which will set out: a. The Services required by the NHS Patient. b. Identify who will perform those Services, and c. Identify all other arrangements which need to be made in respect of the NHS Patient (including transport) on and after Discharge (a Discharge Plan). Notify all relevant parties of the Discharge Plan and any information relevant to the treatment option chosen by the NHS Patient. The relevant parties may include social services, the NHS Patient s GP and other primary care services provided by the NHS and/or other voluntary/charitable sectors; and Provide the NHS Patient with written instructions and information relevant to the NHS Patient s care and recovery If at the First Out Patient Appointment or at a subsequent NHS Patient Appointment the Healthcare Professional assessing the NHS Patient considers that one or more of the following apply: (i) Further tests or investigations which cannot reasonably be carried out at the First Out Patient Appointment are required in order for the Healthcare Professional to make a fully informed decision as to the most appropriate treatment or procedure. (ii) A non-surgical treatment is required before confirming the need for surgery, in which case The Provider shall notify the NHS Patient s GP and the Referring Clinician (if different) of these circumstances; or (iii) The NHS Patient requests a delay to allow them time to consider options proposed by the assessing Healthcare Professional, or any other reason The assessing Healthcare Professional shall inform the Referring Clinician, and subsequent action by The Provider in respect of the admission or treatment of any such NHS Patient shall be delayed by such time as is reasonable by reference to the relevant clinical circumstances. In Patient or Day Case Activity 10.5 In the event that any NHS Patient is listed for an In Patient or Day Case, The Provider shall: (i) Offer the NHS Patient a choice of appointment dates and times: a. Offering the NHS Patient a choice of three (3) Admission dates, at least two of which must be within Reasonable Notice. Ensuring that the NHS Patient does not breach the current Referral to Treatment Times as agreed with The Commissioner. (ii) Provide the NHS Patient with an information package costing of: a. The location and other details of the Facility at which the activity will take place. b. What the NHS Patient needs to do prior to Admission which may include pre-operative classes, physiotherapy and occupational therapy assessment and pre-procedure preparation (e.g. nil by mouth or bowel preparation). c. What the NHS Patient should bring with them to the Facility such as clothes and medication. d. All relevant information about the activity including: 1. What the NHS Patient should expect before, during and after the procedure. 2. The likely duration of recovery from the treatment. 3. What, if anything the NHS Patient should do or refrain from doing after the procedure. 4. How the NHS Patient can get advice after discharge. 5. What the NHS Patient should do if there are problems or the NHS Patient is worried, including relevant contact details; and 6. How to make a comment or complaint to The Provider or about The Provider to another Party. (iii) Explain how the NHS Patient s medical records (including electronic data) will be used for 15

16 (iv) (v) (vi) (vii) (viii) contract management, quality assurance and other purposes which are not directly connected with clinical care of the NHS Patient and obtain consent, in line with current legislation and best practice. Confirm in writing to the NHS Patient the agreed date and time for the Admission within two (2) Business Days of agreeing the date. Provide to the NHS Patient a contact telephone number which will be staffed by a suitably qualified Healthcare Professional to respond to any NHS Patient concern or query following Discharge. If practicable, having regard to the period between the First Outpatient Appointment and the Admission date, issue a reminder to all NHS Patients, by telephone, or SMS text message, forty eight (48) hours before Admission to: a. Confirm their attendance. b. Answer any outstanding questions. c. Confirm that all details remain correct including but not limited to current health status and current address details. If an NHS Patient does not attend on the agreed Admission date then The Provider shall: a. Inform the Referring Clinician within 24 hours of that non-attendance; and b. If the agreed Access Policy and/or the Clinical Status of The NHS Patient requires, contact the NHS Patient to rearrange the admission. In the event that The Provider is of reasonable opinion that the NHS Patient is unsuitable for treatment by The Provider as a result of substantiated social, physical or mental health reasons, The Provider shall: a. Refer the NHS Patient back to the Referring Clinician, providing the NHS Patient and the Referring Clinician with a full explanation as to the reasons for its opinion; and b. Record such reasons in the NHS Patient s records. 11 Steps After First Outpatient Appointment and Prior to Admission 11.1 Unless the NHS Patient has undergone a clinical assessment by The Provider in the 2 weeks immediately preceding, The Provider shall ensure that at least two (2) Business Days and no more than five (5) Business Days prior to the date of Admission, the NHS Patient is contacted by a suitably trained member of Staff to: (i) Remind the NHS Patient of the time and location of the Admission. (ii) (iii) (iv) (v) (vi) Confirm that the NHS Patient still wishes to attend. Confirm with the NHS Patient that the NHS Patient s clinical condition remains substantially unchanged since the decision to list the NHS Patient for the activity by The Provider, including making enquiries about intercurrent illnesses, changes in medication and any other relevant factors to minimise the DNA rate. Remind the NHS Patient of any steps he needs to take prior to Admission such as stopping or starting medication and fasting. Confirm that the Discharge Plan is still appropriate to the NHS Patient s circumstances; and Provide the opportunity for the NHS Patient to ask any questions relevant to the Admission or the activity In the event that there has been a change in the NHS Patient s health status, whether temporary or permanent, a suitably trained and qualified Healthcare Professional shall contact the NHS Patient to assess whether he is still for the proposed procedure In the event that The Provider acting reasonably considers that the NHS Patient is temporarily unfit for the proposed procedure, The Provider will take all reasonable steps to confirm that the NHS Patient has access to any primary or secondary care services which may be appropriate or advise the NHS Patient to access such services and to arrange a new date for Admission. The Provider will notify the NHS Patient s GP and Referring Clinician (if different) of all such circumstances and the reasons for The Provider s decision not to carry out the procedure at that time. 16

17 12 Steps on Admission 12.1 On Admission but prior to the commencement of the activity The Provider will ensure that: (i) The NHS Patient s Records include all investigations and results including diagnostic images and scans notified to The Provider or carried out by or on behalf of The Provider. (ii) The NHS Patient s health and social status has been confirmed as current. (iii) The NHS Patient is identified with an identification band and any allergy alert identification band. (iv) Ensuring the NHS Patient is aware that valuables should not be brought or left at the Facility (i.e. the NHS Patient should be encouraged to give any items of value to a friend or relative for safe keeping). (v) Any other requirements during the Admission process which are relevant to the activity have been carried out Following Admission, The Provider shall prepare the NHS Patient for the activity. Such preparation shall be appropriate for the NHS Patient and the activity and shall include: (i) Completion of the pre-intervention/anaesthetic preparation and checklist. (ii) Obtaining and recording consent to proposed assessments are carried in accordance with the appropriate informed Consent requirements of the pathway, and/or that any such consent obtained earlier remains valid. (iii) Surgical, anaesthetic, nursing and other professional assessments are carried out as appropriate. (iv) Reviewing the NHS Patient s pain control. (v) Ensuring the NHS Patient has had nil by mouth for six (6) hours pre-operatively unless Good Clinical Practice requires a longer or shorter period. (vi) Where appropriate, the skin is marked to indicate the surgical site, in accordance with The Provider s risk management or other approved quality assurance policy or procedure. (vii) Providing for the NHS Patient s on-going medication needs. (viii) Administering pre-medication as prescribed. (ix) Providing all such other care as is required or appropriate for that particular NHS Patient or activity At all times during the Admission The Provider shall provide the following information to the NHS Patient. (i) How to summon help. (ii) What is going to happen during Admission. (iii) How to ask questions (and the availability of interpreters). (iv) If applicable, how to make use of the interpretation services available in The Provider s Facility. (v) The access and facilities which are available for escorts and visitors. (vi) Health and safety information (including safety procedures). (vii) Availability of food and refreshments (viii) Visiting times. (ix) Shower/toilet facilities. (x) Ward routines; and (xi) Other services available 13 Anaesthetic 13.1 Where an activity requires Anaesthetics, The Provider shall ensure that such administration complies with the following standards: (i) National Minimum Standards, which includes statutory requirements. 17

18 13.2 The Provider shall develop a plan (the Anaesthetic Plan) which shall include and provide for planning in respect of: (i) Appropriate, safe pre-anaesthetic assessment. (ii) Informed choice of the types of anaesthetic. (iii) A pain scoring system (iv) Appropriate level of NHS Patient recovery needs. (v) Capacity and theatre schedule management (when placing NHS Patients on lists); and (vi) Safe supply and installation of medical gas The Provider will on at least an annual basis or at any time where circumstances arise which suggest the need to review The Provider practice regarding Anaesthetics, audit regional anaesthesia numbers and outcomes and review policies and standards relating to Anaesthetics with The Commissioner The Provider shall ensure that policies for the types of anaesthesia that will be administered in the Facility are in place and are reviewed and updated in accordance with Good Clinical Practice. 14 Use of Blood and Blood Products 14.1 The Provider shall ensure that all use of blood and blood products complies with appropriate National Minimum Standards and guidelines The Provider shall ensure NHS Patient s consent in obtained in relation to the use of blood and blood products The Provider shall ensure that alternative treatment arrangements are made available to those NHS Patients who will not accept blood transfusions The Provider shall ensure that National Blood Transfusion Service standards are adhered to, including guidance for cross matching/ordering blood components, and use of other blood products, such as plasma proteins, albumin, gelofusion and fresh frozen plasma. 15 Prevention and Diagnosis of Deep Vein Thrombosis (DVT) 15.1 The Provider shall ensure: (i) A Provider policy exists to offer appropriate guidance in relation to the prevention and diagnosis of DVT. (ii) Patients undergoing treatment which carries any risk of DVT must be treated prophylactically in accordance with Good Clinical Practice and NICE guidelines. (iii) Patients who are assessed as susceptible to complications consistent with loss of blood are observed for any clinical signs of having developed a DVT or pulmonary embolus (PE) in accordance with Good Clinical Practice and NICE guidelines. (iv) The use of prophylactic antibodies where relevant. 16 Peri-Operative Period 16.1 The Provider shall ensure that all Activities are undertaken: (i) In accordance with Good Clinical Practice; and (ii) In accordance with the terms of this Agreement. 17 Steps During Post-Operative Period 18

19 17.1 On leaving the operating theatre or other location in which an activity has been performed the NHS Patient shall be cared for in an appropriate recovery area until the NHS Patient is fit for discharge No NHS Patient shall be transferred out of the operating theatre recovery area (other than in the event of an unplanned transfer for the purposes of medical care which is required by the NHS Patient and cannot reasonably be provided in the recovery area) until the NHS Patient is clinically fit to be transferred as determined by an Anaesthetist or other healthcare professional to whom an Anaesthetist has specifically delegated such authority For so long as is required during and after the activity and in accordance with Good Clinical Practice, The Provider shall: (i) Provide such emergency support as may be required in relation to any NHS Patient in a level 2 or 3 critical care facility, and if there is not such facility on site, transfer such NHS Patient to a facility with level 2 or 3 critical care facilities using the appropriate transfer and transport, following The Critical Care Network Guidelines. (ii) Monitor vital signs. (iii) Inspect wounds regularly for signs if oozing, infection, dehiscence and other adverse events which may follow surgery. (iv) Monitor the NHS Patient s condition with respect to nausea, vomiting and pain. (v) Administer intravenous fluids (if required). (vi) Offer the NHS Patient food and drink of a type and consistency and at intervals appropriate to his clinical condition, until the NHS Patient is able to take a normal diet. (vii) Procure that clinical assessments are carried out by a one or more Healthcare Professional, having the relevant skills in relation to the activity undergone by the NHS Patient. Without limitation, these clinical assessments should include assessment of the NHS Patient s skin, assessment for signs of deep vein thrombosis in accordance with designated protocols and assessment of the NHS Patient s nutritional status, elimination of urine and faeces and IV Cannula/Infusion. (viii) Review the NHS Patients medication. (ix) Assess the NHS Patient s hygiene needs and general activities of daily living. (x) Review and amend the Discharge Plan prior discharge by reference to the NHS Patient s post-operative course and any other change in circumstances; and (xi) Prior to discharge: a. Provide discharge medication (TTOs) in accordance with the agreed Care Pathway. b. Inform the NHS Patient s GP and any other relevant Parties of any relevant aspects of the Discharge Plan, including the anticipated date of Discharge. c. Complete all required documentation pertaining to patient care. d. Ensure that any modifications to an NHS Patient s equipment have taken place prior to discharge and if these modifications have not been done ensure that such failure(s) are reported back to The Commissioner, Referring Clinician and the NHS Patient s GP (if different) within 24 hours; and e. Following surgery, provide personal equipment and any related training to the NHS Patient and the NHS Patient s nominated carer, if any If at any time The Provider discovers any significant illness or condition requiring further investigation or referral which is unrelated to the Admission diagnosis The Provider shall: (i) Following receipt of confirmation from the NHS Patient s GP and the Clinician (if different), make a direct referral and transfer if required to a relevant specialist clinician for Inpatient care; or (ii) Request additional diagnostics if appropriate and refer the NHS Patient back to the Referring Clinician for onwards referral for Outpatient management. 19

20 17.5 The Provider shall, unless otherwise agreed, provide or procure and be responsible for at its own expense the clinical management (including treatment) of any post-operative complications and incidental infections identified by The Provider whether identified during the Admission of the NHS Patient or arising within 30 days of the activity (the Post- Operative Period) which is or should reasonably be expected to have been identified as being a post-operative complication. In the event that the relevant facilities, resources or expertise to treat the complication cannot be provided by The Provider, The Provider shall arrange admission to a relevant NHS facility. In the event that the NHS Patient requires such medical attention as is referred to in this paragraph, The Provider shall liaise with the Referring Clinician, if appropriate, to determine whether the circumstances arise from any post-operative complication If an incidental infection is identified during the pre-assessment of the NHS Patient including, but not limited to MRSA infection, The Provider shall manage and treat the NHS Patient in a manner consistent with protocols for the management and treatment of such infections by local NHS Trusts, where these protocols exist. Where no such protocols exist, NHS Patients will be treated in accordance with Good Clinical Practice. 18 Post-Operative Analgesia and Control of Post-Operative Nausea and Vomiting (PONV) 18.1 The Provider shall ensure that: (i) The NHS Patient receives a pre-operative explanation of what to expect in terms of post-operative pain, nausea and vomiting. (ii) The NHS Patient s agreed Care Pathway seeks to address and manage post-operative analgesia and post-operative pain, nausea and vomiting. (iii) (iv) An Anaesthetist oversees recovery and is available to prescribe analgesia and antiemitics according to NHS Patient need; and The NHS Patient s condition is observed and monitored by appropriately trained Healthcare Professionals. 19 Steps on Discharge 19.1 Save where an NHS Patient is likely to have a long term incapacity and appropriate arrangements have been made to support the NHS Patient outside the Facility, unless otherwise agreed with the NHS Patient (and any person who will be caring for the NHS Patient after discharge including where appropriate Healthcare Professionals and the NHS Patient s family) The Provider shall not discharge any NHS Patient until that NHS Patient: (i) Is independent in terms of personal care to the extent the NHS Patient was prior to the procedure (where the procedure is not related to improving NHS Patient independence). (ii) Is capable of independent transfer from bed to chair, and bed to bathroom to the extent the NHS Patient was prior to the procedure (where the procedure is not related to improving NHS Patient independence). (iii) Where relevant, knows how to use assisting devices (for example, frames or crutches). (iv) In the case of Day Case Activities, has re-gained normal urinary elimination habits and in the case of Inpatient Activities has regained normal urinary elimination. (v) (vi) Has established normal nutritional habits (for Inpatient cases only). Ensure patient has all the necessary medication, dressings and aids required as a result of the activity for at least 28 days, in accordance with Good Clinical Practice and understands how to take the medication, apply the dressing and use the aids. 20

21 (vii) (viii) (ix) (x) (xi) Is being discharged to a safe environment. Has and understands all relevant follow-up information. Has The Provider s emergency contact number(s) and the NHS Patient or his carer understands under what circumstances contact should be made. Is fit to be discharged, with the NHS Patient s experiencing PONV not being discharged until they are found fit for discharge by the specialist in charge of their care; and Is given a copy of the relevant clinical information being sent to the NHS Patient s GP and Referring Clinician (if different) Where walking or living aids are required for a period in excess of twenty eight (28) days, The Provider shall provide the Service until the NHS Patient is independent of the need of such aids. Following provision of such aids by The Provider for a six (6) week period, The Provider shall liaise with the NHS Patient s GP to secure continuation of provision of such services by the NHS and/or social services bodies In the event that the NHS Patient wishes to be Discharged or discharged against The Provider s advice, The Provider shall: (i) Ensure that the NHS Patient is aware of The Providers opinion that he should not be Discharged or discharged, and the reasons for that provision. (ii) Obtain the NHS Patient s written statement that they wish to be Discharged or discharged against medical advice or, if the NHS Patient is unable or unwilling to sign such a statement, record all relevant details in the Patient s Records to be witnessed by two (2) Healthcare Professionals one of whom should, if possible, be the person responsible for the NHS Patient s care. (iii) Inform the NHS Patient s next of kin, carer or other appropriate person of the NHS Patient s Discharge or discharge against medical advice. (iv) Take any steps to detain the NHS Patient which are appropriate and are legally permitted. (v) Inform The Commissioner as soon as reasonably practical of the NHS Patient s Discharge or discharge against medical advice. (vi) Inform the NHS Patient s GP and the Referring Clinician (if different) prior to, or immediately after, the NHS Patient s Discharge or discharge. (vii) In the case of vulnerable patients, inform the police and/or other support agencies as appropriate; and (viii) Take all reasonably practicable steps to organise the Discharge or discharge as if it were taking place with, rather than against, medical advice On Discharge, The Provider shall update the Discharge Plan and complete all of the Patient s Records and forward copies of the relevant documentation to the appropriate community support agencies including district nurses, social workers and GPs The Provider shall prior to discharge arrange all specialist review or follow up appointments On the date of the Discharge, The Provider shall send to the Referring Clinician a Discharge Summary (which must be provided at the time of the NHS Patient s Discharge) and a Discharge Letter (which must be provided within seventy two (72) hours of the NHS Patient s Discharge) together with the following information: (i) The NHS Patient s full name, full address, including postcode, gender, date of birth, and NHS number. (ii) A description of the procedure carried out (Including Activity Code information). (iii) Any relevant clinical findings, including any from histological specimens obtained in the course of an activity. 21

22 (iv) (v) (vi) (vii) (viii) (ix) (x) A list of all medicines, dressings, aids and period of supply which were prescribed for or provided to the NHS Patient at Discharge or discharge, other than those which the NHS Patient was prescribed prior to Discharge or discharge (provided these remain at the previously prescribed frequency and dosage). Any Information about the condition of the NHS Patient which may be relevant to the NHS Patient s recovery or clinical care whether or not caused directly or indirectly by the activity and whether or not relevant to the NHS Patient s care or recovery relating to the activity including for example wound infection, allergic reaction to a medicine, intercurrent illness. A statement about the timing and nature of any planned follow-up review. Information given to the NHS patient where this differs materially from that which the Referring Clinician or the NHS Patient s GP (if different) would infer from the preceding information (for example, where the NHS Patient has not been told the diagnosis). The name of the Healthcare Professional under whose care the NHS Patient was Admitted. Details of how to contact The Provider in the event that anyone caring for the NHS Patients requires further information, including how to contact The Provider outside normal working hours; and Details of the NHS Patient s referral to other agencies (if any). The Provider must comply with NHS Standard Contract Service Conditions SC11 Transfer of and Discharge from Care 2015_Transfer_Disch arge_policy_generic_v The provider will be required to provide discharge letters to patients on discharge and within 24 hours to the patients GP. Response times and prioritisation 20 Emergencies 20.1 For all Services The Provider shall: (i) Ensure that sufficient Staff with appropriate skill, training and competence are available to maintain patient safety at all times when patient s are in the Facility. (ii) Ensure that appropriate Healthcare Specialist on-call arrangements are in place The Provider shall ensure that: (i) It has at each Facility adequate equipment, medication, fluids and transfer arrangements to deal with medical emergencies in accordance with standards stipulated by the Care Quality Commission, including, but not limited to, to a deterioration in the patient s clinical condition whether gradual or sudden, an intercurrent illness such as an infection, or an intercurrent event such as myocardial infarction whether or not such circumstances are related to the procedure or have been in whole or in part caused by The Provider s negligence or failure. (ii) The Provider has the procedures to deal with medical emergencies, including 22

23 (iii) (iv) NHS STANDARD CONTRACT without limitation, immediate treatment, stabilisation and arranging for the transfer of the NHS Patient to an appropriate NHS Trust which can provide the level of critical care required and any other steps that could reasonably be required to minimise the adverse consequences of the medical emergency, including using, where appropriate, locally agreed transfer protocols where these exist, including: a. Complying with the latest UK Resuscitation Council guidance on Advanced Life Support and all future updates/revisions. b. Complying with the Critical Care Network guidance. It shall not provide Clinical Services to NHS Patients who have a medical contraindication to the specific activity; and Ensure that it maintains a safe environment for NHS Patients, Staff and Visitors to the Facilities, employing an appropriate risk management strategy to minimise potential hazard Non-Provision of Required NHS Patient Referral Information The Provider shall be entitled to reject any Referral until the Clinical Minimum Data Set has been provided. However The Provider may only reject a Referral and not complete the activity if the NHS Patient Referral Information remains incomplete despite The Provider requesting the required information; and (viii) (ix) To proceed with the activity would be clinically unsafe; or The Provider does not have sufficient NHS Patient Referral Information to be able to treat the NHS Patient within the agreed Referral to Treat Waiting Time. 23

24 Patient Referral received Clinician Review if required No Diagnostic s Yes MR: CT: Pathology: Dexa Scanning: Inter-Provider Transfer Return to GP No Fit for Surgery or Date for Admission Yes Clinician Services Inpatient Diagnostics Resident Medical Officer Physiotherapy Pre Discharge Planning District Nurse Occupational Therapy Social Services PTS Follow up Treatment Yes Follow up No Patient Discharged from care 24