Sussex NHS Commissioners



CWS Locally Commissioned ServiceService TitleService Code12 Lead Electrocardiogram: Locally Commissioned ServiceCWS-LCS028IntroductionAll practices are expected to provide essential and those additional services they are contracted to provide to all their patients. This Locally Commissioned Service (LCS) specification outlines the more specialised services to be provided. The specification of this service is designed to cover the enhanced aspects of clinical care of the patient, all of which are beyond the scope of essential services. No part of the specification by commission, omission or implication defines or redefines essential or additional services.This service must be provided in a way that ensures it is equitable in respect of race, creed culture, diversity, disability, age etc.By signing up to provide this service as an LCS, you are agreeing to ensure the provision of this service is accessible to all patients registered to your practice who are deemed to clinically require this serviceBackgroundThe provision of 12-Lead electrocardiogram (ECG) services in Primary Care has significant benefitsimproving the quality of primary care servicesproviding a more convenient service to patientshelping to relieve the pressure on secondary care services. ECG provision is not covered by the GMS (PMS or APMS) contract. This Locally Commissioned Service (LCS) recognises the commitment within Primary Care to provide 12 Lead ECGs to patients and the increasing demand placed on providers to do so. It will deliver care and early reassurance to patients in GP practices, provide early indication of rhythm abnormalities and prevent some referrals to secondary care. Aim of Service2.1Purpose of serviceThis Locally Commissioned Service will Enable practices and primary care clinicians to provide 12 Lead ECGs to their patients, providingimproved quality of primary care servicesmore convenient services for patientsEnsure equity of service for patients across Coastal West Sussex CCGPrevent avoidable referrals to hospital for 12 lead ECGsImprove the detection of atrial fibrillation in Primary Care2.2Scope of serviceThis service is intended to provide ECG services for patients in primary care, usually therefore at the behest of clinicians working in primary care (GMS PMS and APMS) services.Other providers (secondary care, mental health, eating disorders for example) sometimes ask primary care providers to perform an ECG. This may be for a variety of reasons. For the avoidance of doubt, this specification is not intended usually to provide an ECG service at the behest of clinicians working within other providers. Such ECGs should normally be provided ‘in house’ within other providers or referred to specialist cardiology services.Examples would include,Eating disorder services – monitoring ECGs should be provided within the eating disorder service and not be requested from primary care (with the exception of ECGs for the purpose of referral into eating disorder services or indicated when eating disorder patients present to primary care unwell)Mental health services – monitoring ECGs should not be requested from primary care providers (please see SPFT policy flow diagram (Appendix A)Secondary care services – ECGs should be performed within the hospital serviceThe specification does not include ECGs done for the purposes ofany ‘routine’ medical examination/assessment.pre-operative assessment (to be absolutely clear pre-operative assessments should not be undertaken in primary care)2.3Population coveredAll patients registered with any Coastal West Sussex GP practice are eligible. Participating practices should accept referrals from non-participating practices within their PCN.The practice carrying out the 12-Lead ECG must, in addition to undertaking the ECG, also clinically review the ECG tracing before the patient leaves to ensure that no immediate action is required. If the interpretation warrants immediate action, then the practice providing the ECG is responsible for acting appropriately. In all other circumstances the ECG should be sent to the registered practice within 24 hours of the ECG being undertaken. 3 Clinical Specification3.1. Indications for ECG in Primary CareThis will be at the absolute discretion of the primary care clinician as the ordering party.Indications include but are not limited to,The investigation of symptoms including:Breathlessness/dyspnoeaChest discomfortPalpitations and suspected AFSyncope/dizzinessPossible TIA/strokeDrug monitoring (QTc monitoring) where clinically indicated and at the discretion of the primary care clinicianAnorexia nervosa either for the purposes of initial referral or at the discretion of the primary care clinicianHypertension where indicated (NICE Guidance)Please notePatients presenting with acute symptoms that might suggest myocardial infarction should be transferred immediately to A&E by calling 999. A normal ECG does not exclude myocardial infarctionThere is no requirement or obligation to perform a 12 lead ECG routinely as part of referral to cardiology services, in particular if the ECG does not alter the decision to refer. The ECG will be repeated or performed in secondary care routinely.3.2 Exclusion CriteriaECGs undertaken for the following reasons may not be claimed under this LCS:Any ‘routine’ medical examination/assessment.Pre-operative assessment (these should not be undertaken in primary care)None of the above changes the proper approach regarding ECGs in other providers, which is that they should perform or arrange their own ECGs, where these are indicated, without involving primary care. See Appendix A (SPFT policy flow diagram).4 Equipment4.1 Quality Requirements The Provider is responsible for ensuring the service is provided in a suitable setting and from premises registered with the Care Quality Commission (CQC). Equipment must meet all criteria set out in national and local guidance relevant to the service being commissioned. 4.2 EquipmentIt is the Practice’s responsibility topurchase equipment to enable it to deliver the Service. replace equipment that has reached the end of its lifespanpurchase all consumables ensure that all equipment is maintained in line with the manufacturer’s guidanceEquipment costs are included in the pricing.5 Quality Service Standards5.1 Applicable national standards (e.g. NICE)The provider is required to ensure that there is a system in place to ensure that any and all required national standards or clinical guidelines are identified and adhered to, in order to deliver a safe and effective 12 lead ECG service to patients where required. The link below outlines the latest guidance available at the time of writing out lining key NICE guidance:[{%22ety%22:[%22Guidance%22]}]&q=ecg+guidelines&sp=on5.2 Applicable standards set out in Guidance and/or issued by a competent bodyThe provider will ensure that the principles of the standard are applied where required: “Clinical Guidance by Consensus; Recording a Standard 12 Lead ECG; An approved methodology by the Society for Cardiology Science and Technology’” (June, 2017) Location of Service providers’ premises 6.1 Providers premisesThis ECG service should be provided at a GP practice as stated on page 3 of the NHS Standard Contract. 6.2 ConsentIn every case the patient should be fully informed of the treatment options and the treatment proposed where appropriate. 7 Clinical Governance and Record KeepingAll practices providing ECG’s must have a system in place where a suitably trained clinician reviews the ECG recording immediately, and before the patient has left the building. In cases where immediate action is required it is the responsibility of that clinician to ensure appropriate actions.All ECGs should be made available to the ordering clinician / practice within 24h. With the exception of ECG recordings requiring immediate action, the interpretation and ongoing care of the patient is the responsibility of the ordering clinician.All practices must have written Standard Operating Procedures (SOP) in this regard which must be made available to the CCG on request as a requirement of this service.The handling of consumables and associated activities (e.g. procurement, storage, prescribing, and disposal of consumables) should be covered by the Standard Operating Procedures and must be safe and in line with current legislation, licensing requirements and good practice, including national guidelinesFor the purposes of payment, practices must have a system in place to differentiate between ECGs that they have performed themselves for the clinical reasons given above, from ECGs provided within other providers but recorded in their clinical system, and ECGs performed for the purpose of routine medical examinationClinical Governance arrangements for this service is as set out in Schedule 5 of the NHS Standard Contract. In addition, the provider will be required to evidence an effective system of clinical governance, and put in place appropriate and effective arrangements for quality assurance, continuous quality improvement and risk management.The Provider must demonstrate to the Commissioner that robust, auditable systems are in place to cover responsibility, reconciliation, record keeping and disposal requirements for which it is responsible, as appropriate to this service.8 TrainingGP Practices will offer standardised and clinically effective primary care ECG service to primarycare patients which complies with the standards set out by the Clinical Guidelines by Consensus – Recording a standard 12-lead electrocardiogram (British cardiovascular society).It is the responsibility of the practice providing the service that those carrying out the procedure and are appropriately trained to do so.It is also for the practice to ensure that appropriately trained clinicians interpret the ECG readings. 9 PaymentDescriptionPrice per procedure12 lead ECG ordered and undertaken in primary care?20.13Payments will be made monthly to practices on submission of practice multi-claims.Claims for payment are submitted as part of the LCS multi-claim form.10 Performance Monitoring and Key Performance Indicators (KPIs)10.1 Performance MonitoringCoastal West Sussex CCG reserves the right to request supporting information on an ad-hoc basis, which may include,Evidence of a clear record in the patient notes of the clinical indication for a 12 lead ECG. Evidence of adherence to recognised clinical guidelinesStandard Operating ProceduresAs part of their annual appraisal, clinicians performing procedures should audit the outcomes.10.2 Outcomes / Audit?Number of 12-Lead ECG?Number of 12-Lead ECG consultations on non-regular/ registered patientsDetails of any complaints or serious incidents related to this service are to be submitted annually to the CCG.11 Post Payment Verification (PPV)Coastal West Sussex CCG, as lead commissioner, has responsibility to ensure all services provide value for money and deliver safe quality care. The commissioner may request evidence to ensure payments made to providers under this agreement are in line with the contractual requirements outlined in the specification and valid as per the claim criteria and time frames specified. The commissioner may request, at any time, evidence to support any claims made or details of any sub-contracting arrangement, details must be provided within the requested timescale. Where possible the commissioner will use tools available to validate expenditure and activity using available existing data i.e. audits and returns by providers and will aim to prevent repeat requests. 12 Breach and Termination Notice12.1 Termination periodEither party can terminate the service outlined in this specification by providing 3 months’ notice, in writing. Termination of a single or multiple LCS service(s) does not affect all services listed within the NHS Standard Contract, unless specified. Individual service termination is required for each commissioned service and will need to be clearly specified. Upon termination of a service the provider will remain responsible for managing the closure of clinics and advertising the service change to their registered population and stakeholders. This will include cancelling any booked clinics and assisting in the re direction to alternative providers. At the end of the termination period the provider must make all activity claims as per the quarterly process. Any payment applications for claims made after a service has expired will be reviewed by the commissioner on an individual basis and payment will be discretionary.Breaches and terminations will be in accordance to the NHS Standard Contract 13 ReviewThis LCS will be reviewed annuallyDateReviewer/sDate Published01/10/19Bruce Allan/Glyn WilliamsDate Reviewed 00/00/00Appendix A: Flow diagram to illustrate SPFT policy pathway. ................
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