NHS Standard Contract - Service Specification Service Specification Service Final 24hour Ambulatory Blood Pressure Monitoring (24hrABPM) Commissioner Lead Lead Andrew McMylor / Dr Nicola Jones Jeremy Fenwick, Battersea Healthcare CIC Period 1 st April 2016 31 st March 2018 Date of Review June 2017 1. Population Needs 1.1 National/local context and evidence base National Context High blood pressure (hypertension) is described by NICE as one of the most important preventable causes of premature morbidity and mortality in the UK. Hypertension is a major risk factor for ischaemic and haemorrhagic stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death. Untreated hypertension is usually associated with a progressive rise in blood pressure. In August 2011 NICE issued guidance on the Clinical Management of Primary Hypertension in Adults which is current at the time of writing this specification and is due to be reviewed in September 2015. NICE recommends ambulatory blood pressure monitoring to identify hypertension. This service is commissioned over and above that which General Practices are paid to deliver through the national Quality and Outcomes Framework (QOF). In 2014/15 the threshold included within QOF standard HYP0002 was amended to 150/90mm Hg where it had previously been 140/90mm Hg which was in-line with NICE guidance. For the avoidance of doubt the eligibility criteria for this Service is 140/90mm Hg in-line with NICE guidance. Local Context Following publication of the NICE guidance in 2011, in April 2012 Wandsworth Clinical Commissioning Group (then South West London Wandsworth Borough Team) commissioned a 24hr ABPM service from General Practices as a Local Enhanced Services to support diagnosis of hypertension. 2013/14 QOF data shows that the actual prevalence rate for hypertension in Wandsworth was 31,172 patients against an estimated 71,315 patients (Public Health England, Cardiovascular Disease Profile for Wandsworth) meaning that there are an estimated 40,143 patients who are currently undiagnosed and are therefore not receiving treatment for their condition. Over the past two years since a primary care 24hr ABPM service has been commissioned, there were 1,520 tests performed in 2012/13 and a very similar 1,576 tests performed in 2013/14. In 2012/13 the hypertension register increased by 429 patients, compared with the previous two years where the increase was much lower (+204 in 2010/11 and +113 in 2011/12). In 2013/14 the number of patients on the hypertension register fell by 116 patients. Currently the 24 hr ABPM service is available at 8 of the 9 general practices within West Wandsworth, 11 of the 12 practices in Battersea and 15 of the 21 practices in Wandle. The new provider must be able to improve on this current coverage, providing care close to home and continuity of care for patients. 1
2. Outcomes 2.1 NHS Outcomes Framework Domains & Indicators Domain 1 Preventing people from dying prematurely X Domain 2 Enhancing quality of life for people with long-term conditions X Domain 3 Helping people to recover from episodes of ill-health or following injury Domain 4 Ensuring people have a positive experience of care X Domain 5 Treating and caring for people in safe environment and protecting them from avoidable harm X 2.2 Local defined outcomes To contribute towards increasing the number of patients identified as hypertensive; To avoid unnecessarily labelling patients as hypertensive and therefore reduce unnecessary prescribing of anti-hypertensive medication; Following diagnosis as hypertensive, to initiate treatment for hypertension before the onset of target organ damage; To accurately monitor patients with hypertension for whom 24hrABPM is the most appropriate method of monitoring blood pressure; To shift activity from secondary to primary care where appropriate. 3. Scope The Service will be provided in clinics within general practices and is commissioned to meet the needs of two distinct cohorts of patients: To confirm or rule out a diagnosis of hypertension; To monitor the blood pressure of patients who are already diagnosed as hypertensive and have white coat syndrome who meet with the eligibility criteria set out in section 3.4. 3.1 Aims and objectives of service To ensure the accuracy of diagnosis and monitoring of blood pressure for the patient groups identified through the provision of a quality assured service; To offer all patients an appointment within 4 weeks of request or sooner if clinically indicated; To keep waiting times within the clinic to a minimum and to inform patients of the reasons for any delays experienced; To offer a service which is accessible and convenient for patients; To actively and continually seek feedback from patients on the Service they have received and to use this to shape service delivery. 2
3.2 Service description/care pathway Please see appendix 1 for the hypertension care pathway which details when 24hrABPM would be offered to a patient. 24-hr ABPM In the delivery of this service, the will adhere to the British Hypertension Society s Standard Operating Procedure for Ambulatory Blood Pressure Monitoring which can be found here http://www.bhsoc.org/resources/abpm/. As part of their business as usual, referring GPs will identify patients who require 24hABPM using the criteria detailed under 3.3 and 3.4. Following a consultation, the referring GP recommends 24hrABPM and a referral is made to the 24hrABPM service. The will have in place a written standard operating procedure which will be agreed with the Commissioner prior to the contract being issued. The s written procedure will form an appendix to this Contract and must as a minimum detail how the will: Manage referrals into the service including assessment against eligibility criteria and the process for rejecting and promptly notifying the referring GP of inappropriate referrals; Contact patients to arrange two appointments for the patient, the first to fit the device, explain what the patient must and must not do and to answer any questions. Also to provide a contact telephone number should the patient need help while wearing the device; Provide information to the patient on the service offered (see Appendix 2 Southwest London Cardiac and Stroke Network s ABPM Patient Diary and Appendix 3 Southwest London Cardiac and Stroke Network s Patient Information Leaflet); Provide the patient with written confirmation of their appointments and patient information leaflet in advance of their appointment dates; On the second appointment to remove the device from the patient, print out the report and take back the completed diary from the patient; Promptly and securely reporting back the results of the test to the referring GP securely (see IM&T requirements); Recording the results of the test onto EMIS; Capture the data fields required under section 5. Follow-up after 24hr ABPM Although not commissioned within this service, the referring GP is responsible for ensuring that the results of the test are communicated to the patient, and that any further actions are taken to manage the cardiovascular risk of the patient. 3.3 Population covered The service is available to patients who are registered with a GP in Wandsworth, who are referred by their GP and who fall within the acceptance criteria (see 3.4). 3.4 Acceptance and exclusion criteria and thresholds 24hr ABPM Acceptance Criteria: All patients must be 18 years or over; i. Diagnosis: Patients who do not have an existing diagnosis of hypertension but are identified as having clinic blood pressure of 140/90 mmhg through two readings on different days ; ii. Monitoring: In patients who have been identified as having white coat * effect at diagnosis of hypertension, ABPM can be used as an adjunct to usual blood pressure monitoring to assess response to treatment. Where a patient has been monitored more than twice in a single 12 month period, then the CCG may request further information from the practice; iii. Monitoring: Patients who have not been identified as having white coat syndrome at diagnosis but whose clinic blood pressure is not to target. In this scenario, GP must review lifestyle and check medication compliance with the patient, addressing any modifiable changes which may be contributing to an elevated blood pressure, before 24hrABPM may be offered* If the 24hr ABPM indicates the patient does not have white coat syndrome then the patient can be 3
monitored with clinic blood pressure readings in future and is not eligible for further 24hr ABPMs. If the 24hr ABPM indicates the patient has white coat syndrome then the patient will now fall into category ii.* *NICE defines white coat syndrome as A discrepancy of more than 20mmHg systolic and/or10 mmhg diastolic between clinic and average daytime ambulatory blood pressure monitoring or average home blood pressure monitoring measurements at the time of diagnosis. http://pathways.nice.org.uk/pathways/hypertension **Criteria iii is new to this service, enabling GPs to use 24hrABPM appropriately to a wider group of patients. There is a limited budget allocated to this service and it is unclear how many additional tests this change will generate. Therefore Wandsworth Clinical Commissioning Group will impose a cap on activity during each year. If / when this cap is reached during the year, criteria iii will be removed for any tests performed above the agreed threshold and the provider will only be paid for activity that falls within criteria i or ii. Exclusion Criteria i. Patients under 18 years of age; ii. Patients registered with a GP outside of Wandsworth; iii. Patients who do not have the conditions explicitly referred to in the inclusions criteria. 3.5 Training, Skills and Experience The Service will be provided by a nurse or healthcare assistant who must have received training and be confident in the use of the specific device used by the, this includes: The principles of traditional blood pressure measurement; Undertaking patient consultations; Cuff fitting; Monitoring function and analysis; Reporting results on EMIS web; The must ensure that there is appropriate support and supervision available for those providing the service which is underpinned by the s supervision policy. The will ensure that staff providing the service keep up with their continuing professional development. At least annually any nurses or healthcare assistants providing the service will access current best practice information from the British Hypertension Society website. The nurse or healthcare assistant will sign a declaration to confirm they have done this to be maintained by the as evidence. 3.6 Equipment The must use a device which has been tested according to the revised BHS protocol (1993). For further details please see http://www.bhsoc.org/bp-monitors/bp-monitors/; It is the s responsibility to clean, calibrate and arrange for serving of the device in line with the manufacturer s guidance; It is the s responsibility to purchase all equipment and consumables (such as replacement cuffs and batteries); It is the s responsibility to monitor the life span of the device and to purchase a new device as required. Again this cost will be borne by the as it is built into the service price. 3.7 Interdependence with other services/providers The will develop relationships with other providers in order to become an integral member of the Health and Social Care Community. Wandsworth Clinical Commissioning Group (CCG); All Wandsworth general practices including GPs, practice nurses and healthcare assistants; Blood Pressure units at local acute hospitals; Third sector organisations; Wandsworth Borough Council; Service users as key stakeholders; 4
Healthwatch; 3.8 Finance and Activity The will be paid 20 for each ABPM test performed. Payment will be made for activity which is coded within EMIS using the code below and is subject to the also delivering on the qualitative elements of this specification. Meeting the eligibility criteria After ABPM is performed Reporting requirement Read code What is this used for? Clinic blood pressure Systolic blood pressure To identify patients who reading thresholds for = 2469. meet with the eligibility ABPM: Diastolic blood pressure criteria for ABPM (i.e. for >/=140/90mmHg for = 246A. diagnosis) cross reference <80yrs with age Age No code required Patient is 18yrs or older Age 18-79 No existing hypertension diagnosis No code required Age 80+ To identify only patients who meet with the eligibility criteria for ABPM (i.e. for diagnosis) ABPM performed 315B To record activity note, this is then cross referenced with eligibility criteria to calculate payment ABPM performed patient of other practice Ambulatory blood pressure reading The is required to have its own system to identify a) which practice patients were referred from and b) where these patients received this service and will be required to report this to the CCG on a monthly basis to accompany the EMIS reported activity. Average day interval systolic blood pressure = 246Y Average day interval diastolic blood pressure = 246X Outcome of the test used for QOF Evidence of white coat hypertension diagnosis. White coat hypertension A discrepancy of more than 20mmHg systolic and/or10 mmhg diastolic between clinic and average daytime ABPM or average HBPM blood pressure measurements at the time of diagnosis 246M Please note that there is no read code for 'white coat syndrome', so please use code 246M (the code for white coat hypertension). This read code will not place the patient on the QoF hypertension register, unless there is another qualifying read code also e.g. Essential Hypertension Ensure that this is recorded at time of diagnosis as ABPM can be used for monitoring response to treatment in future. 4. Applicable Service Standards 4.1 Applicable national standards (eg NICE) GC127: NICE Clinical Guideline on Clinical Management of Primary Hypertension in Adults. 4.2 Applicable standards set out in Guidance and/or issued by a competent body (eg Royal 5
Colleges) Standard Operating Procedure for Ambulatory Blood Pressure Monitoring (ABPM); Clinic Checklist Pre ABPM Monitor Attachment. 4.3 Applicable local standards Please see section 3. 5. Applicable quality requirements and CQUIN goals 5.1 Applicable Quality Requirements (See Schedule 4 Parts [A-D]) The will submit the following quality information to the Commissioner. QR1 QR2 QR3 QR4 QR5 Data line Source Frequency What does this tell us? The s operational procedure Pre That the provider has in place an covering the contract operational procedure which meets the requirements of 3.2 requirements of the service specification Provide copy of staff management / supervision policy Names of staff providing the service and confirmation that their training meets the requirements set out in section 3.5 Declaration that equipment used in delivery of the service meets the requirements of 3.6 Reporting on any significant untoward events in line with NHS England framework, including action taken by the. manual manual Pre contract Pre contract then annually Pre contract then annually By Exception The has a system of support in place for staff and ensuring standard operating procedures are adhered to. That staff have the right qualifications and skills to perform the test properly, so that the results are reliable therefore minimises patient risk That the equipment used by the provider in delivery of the service meets with the relevant requirements. Ensures that the CCG is aware of any events as they happen and that the has followed the NHS England framework 6. Premises The provider must be able to improve on this current coverage, providing care close to home and continuity of care for patients. All premises and equipment to be used must be subject to proper maintenance, the responsibility for the provision of suitable premises and equipment will be with the provider and must be relevant to the service, including as a minimum: 1. Premises must be DDA compliant either ground floor or with lift access if not; 2. Premises to enable safe and convenient patient access in relation to transport links; 3. Adequate seating to enable all patients to sit while waiting, including chairs for patients who have difficulty sitting low down. 4. WC facilities should be provided; 5. Have access to interpretation and translation services; 6. Ensure that all premises and equipment to be used is subject to proper maintenance; 7. Decontamination and clinical waste disposal as appropriate; 8. Toilet access (DDA compliant); 9. Hand-washing facilities for provider/patients; 10. Non-slip flooring; 11. Patient changing facilities/curtain area; 6
12. Storage facilities for consumables. 7