Advanced Services
Advanced services are optional and both Dispensing Appliance Contractors (DACs) and Pharmacy Contractors (PCs) are able to choose to provide one both options listed below:
For Advanced Services both contractors are paid a set of fees based on the criteria requirement for providing the service. For payment information please see the table illustrated at the end of the section explaining the Advanced Services.
In addition to the change in remuneration for services, the DH cut reimbursement prices in the drug tariff by 2% from April 2010. This only applies to certain products listed in Part IX A, B and C. For more information see the Part IX Reimbursement section below.
If a Pharmacy Contractor intends on providing either of the advanced services then the terms of service must be complied with from or before the time at which the Pharmacy Contractor proposes to provide the new services. A Pharmacy Contractor can choose to give one months notice prior to providing an advanced service at any time in the future, however should a Pharmacy Contractor decide to opt out of providing this advanced service they must give three months notice
Stoma customisation
The aim of a stoma customisation is to ensure the proper use and comfortable fitting of the stoma appliance by a patient throughout the duration of usage of the appliance, thereby reducing wastage.
Stoma appliance customisation is the customisation of a quantity of more than one stoma appliance, where:
- The stoma appliances to be customised are listed in Part IXC of the Drug Tariff i.e. customisation is required by the patient
- The customisation involves modification to the same specification of multiple identical parts for use with the appliance
- That modification is based on the patient's measurement or record of those measurements and if applicable, a template.
Requirements for the service
The NHS Commissioning Boards (NHSCB) and NHS Business Services Authority (NHS BSA) must be notified of the intention to provide the stoma appliance customisation service by the last working day prior to the month in which the service is to be provided.
The supplier of appliances must be satisfactorily complying with the obligations for Essential Services for the supply of appliances and must have an acceptable system of clinical governance in place within the premises. They must have procedures in place to ensure referral to the prescriber, where a customised stoma appliance is not suitable for further customisation. Or where a stoma appliance has been customised and is not a proper fit for the patient.
Stoma appliance customisation must be provided at an 'acceptable location' as specified below:
- An area within the premises which:
- is distinct from general public areas
- at all times when stoma appliance customisation services are being provided, is clearly designated as a private area
- is suitable and designated for the retention of the appropriate equipment for stoma appliance customisation
- is suitable and designated for the carrying out of modification of stoma appliances
- is suitable and designated for the volume of stoma appliances that may be customised at any given time.
- An area elsewhere than at the supplier's premises which:
- is distinct from the general public areas of the premises in which it is situated
- meets all the other requirements above
The standards for the location where stoma appliance customisation is undertaken is to ensure patient dignity and privacy. For some DAC premises, patients may only attend for this service and in this instance, the DAC should ensure they have an area where the appliance can be customised in comfort for the patient. For many Pharmacy Contractors they will already have a room where they undertake Medicines Use Reviews and this may well be deemed to be acceptable.
Where the service is to be provided elsewhere other than at the supplier's premises, procedures are in place to ensure co-operation with any reasonable inspection or review of the area by the NHSCB. It may not be possible for the DAC or Pharmacy Contractor to provide this service from their premises e.g. a lack of an acceptable location. In this instance it is permissible for the service to be provided at an alternative address. However, the NHSCB must be able to inspect these premises and it must still comply with all the standards for an area within the contractor's premises.
With regards to how large the acceptable location is, this will be for the NHSCB to determine. Not only must it be large enough to hold all necessary equipment, it must also allow the patient and the person providing the service sufficient room to sit and move around in. Suppliers of appliances who provide a considerable number of stoma appliance customisations would be expected to have a larger area than one who only does a few each month. Suppliers of appliances are encouraged to discuss this with their NHSCB before commencing the provision of this service.
Additional requirements for the service
Only appropriately trained and qualified persons are permitted to customise an appliance. Neither the Directions nor the Drug Tariff specify what training and/qualifications are deemed appropriate for the provision of this service. NHSCB’s and suppliers of appliances should therefore discuss what would be appropriate in advance of this service being provided.
A record of each customisation must be completed. The record must contain the minimum requirements as stated within the Directions (see below). This may be in the form of a paper record or electronic record. The record must be retained for a minimum of 12 months unless the NHSCB has specified longer.
A copy of the record must be supplied to the patient or, if requested by the patient, to the prescriber or other healthcare professional.
Record keeping for stoma appliance customisation
The records made and retained can be in either paper or electronic form and should be retained for a period of no less than 12 months or a longer period as specified by the NHSCB. Each record must include:
- Details of advice given
- The type of stoma appliance customised
- Dimensions used in respect of the modification of parts of the appliance
- Measurements of the patients (if taken)
- Dimensions of any template made or modification of any existing template
- Any referral made to the prescriber
- Any other details that are deemed appropriate or specified in the arrangements made with the supplier of appliances.
Withdrawal from the service
If a supplier of appliances wishes to withdraw stoma appliance customisation, three months' notice must be given to both the NHS BSA and the NHSCB of their intention to do so.
Appliance Use Reviews
The aim of the AUR service is to improve patient knowledge, concordance and use of specified appliances by:
- Establishing the way the patient uses the specified appliance and the patient's experience of such use
- Identifying, discussing and assisting in the resolution of poor or ineffective use of their appliance
- Advising the patient on the safe and appropriate storage of the specified appliance
- Advising the patient on the safe and proper disposal of any specified appliances that are unused or unwanted
An AUR can be provided when a pharmacist or specialist nurse visits a patient at home or when a patient visits the premises of the supplier of appliances.
Suppliers of appliances may choose to provide AURs in relation to Part IXA (qualifying items*), Part IXB or Part IXC prescription items. Such reviews must be conducted by a specialist nurse - working on behalf of the supplier of appliances that dispensed the appliance - or by a pharmacist.
AURs are intended to complement the care provided by healthcare professionals working in the NHS, therefore the specialist nurse - working on behalf of the supplier of appliances - or pharmacist must maintain close contact with the NHS healthcare professional looking after the user, where possible.
AURs may take place at the user's home or at the supplier of appliances' premises. However, if the AUR takes place at the supplier of appliances' premises, there are certain minimum standards that the area must meet - see box below. These standards are similar to those that pharmacy contractors are required to meet when providing Medicines Use Reviews
Requirements for the consultation area where an AUR may be provided
The area must be:
- Distinct from the general public areas
- Clearly designated as an area for confidential consultation at all times when a pharmacist or specialist nurse is reviewing the use of an appliance
- Allow all persons taking part in the review to sit down together and talk at normal speaking volume without being overheard by other visitors to, or staff at, the premises
- Have regard to the nature of the appliance and the underlying purpose of the AUR, is suitable for a consultation to determine how a patient uses an appliance and the extent of the patient's knowledge about it
Requirements for the service
Before any arrangements are entered into, the NHSCB and NHS BSA should each be supplied with the correct notice that the supplier of appliances wishes to provide AUR service and a statement of where the service will be provided from.
Before any arrangements are entered into, the NHSCB has also been supplied with the required details of each of the pharmacists and/or specialist nurses who will be providing the AUR service. The details that are required are:
- Full name
- Documentary evidence of qualifications (or education, training or experience)
- Details of competency (or relevant clinical training and practice) in respect of the use of appliances
Again, neither the Directions nor the Drug Tariff set out any particular qualifications that are required by the healthcare professional providing this service, unlike for the provision of Medicines Use Reviews. NHSCB’s and suppliers of appliances should therefore look at the experience and continuous professional development of the specialist nurse or community pharmacist providing the service. However, it is not for the NHSCB to assess the competency of the individual.
The supplier of appliances must:
- Be satisfactorily complying with the obligations for Essential Services
- Have an acceptable system of clinical governance
- Have procedures in place to ensure referral to the prescriber, where a matter relating to the patient's use of the appliance arises during the AUR.
If an AUR is to be provided at the supplier of appliances' premises there is a consultation area which meets the requirements as previously detailed above. Pharmacy Contractors will note that these standards are very similar to those for the provision of Medicines Use Reviews. However, due to the nature of specified appliances it is likely that hand-washing facilities will need to be available in the consultation area. NHSCB’s may therefore wish to discuss with their suppliers of appliances what standards would be required to meet infection control standards.
Additional requirements for the service
Only appropriately trained and qualified persons (pharmacists and specialist nurses) are permitted to provide the AUR service. This is similar to the advanced service provided by Pharmacy Contractors, where Medicines Use Reviews must be provided by a pharmacist. This requirement ensures that the healthcare profession providing the service works within their competencies, and if they work outside their competence then they may be subject to investigation by their professional regulatory body.
Where reasonably possible an AUR must be provided within 2 working days of the day on which the patient requests a review or agrees to one at the suggestion of the supplier of appliances.
The pharmacist or specialist nurse providing the service must obtain the patient's prior written consent to receiving the service.
The patient must be informed in writing that a record will be kept of the AUR and that certain information resulting from the service will be forwarded to the supplier of appliances and an appropriate healthcare professional involved in the care of the patient e.g. their registered GP.
A record of each AUR must be completed. This can be paper or electronic, and must be forwarded to the supplier of appliances.
Each record must include the information listed below:
- The date of the AUR
- Name of the pharmacist or specialist nurse providing the service
- Name of the patient
- Address the service was carried out
- Name of any other person present (and their relationship)
- The reason why a review is required
- Advice given to the patient
- Any intervention made.
The record must be kept for a minimum of 12 months, or longer if specified by the NHSCB.
The information contained within the record and any other useful relevant information must be forwarded to the patient's GP and any other healthcare professional, including any NHSCB nurse, providing care for that patient.
Payments for AURs
- AURs conducted at the supplier of appliances' premises - £28 per AUR
- AURs conducted at the user's home - £54 per AUR
- Where more than one AUR is conducted in the same location within a 24-hour period - £54 for the first AUR and £28 for each of the subsequent AURs.
The maximum number of AURs for which a supplier of appliances is eligible for payment in any financial year is not more than 1/35th of the aggregate number of specified appliances dispensed during that financial year. Suppliers of appliances must self-declare in the monthly return form (FP34) the number of AURs conducted.
When claiming for AURs the FP34 form will have different boxes for the two different AUR rates (£28 and £54). Suppliers of appliances will need to specify how many of each rate they are claiming for.
With regard to more than one AUR being carried out at the same location in a 24-hour period, the first AUR needs to be claimed as if it had been carried out at a user's home and subsequent reviews at the same location need to be claimed as if they had been carried out at the supplier of appliances' premises.
Advanced Services Fee Structure Table
| Service | Requirement | Fee Level |
|---|---|---|
| Stoma Customisation | The process of modifying multiple identical parts for use with a stoma appliance to the same specification, where the modification is based on the patient's measurements or record of those measurements and, if applicable, a template. | £4.32 for every qualifying Part IXC prescription item dispensed, the fee is paid per qualifying Part IXC item dispensed, regardless of whether customisation is required. |
| Appliance Use Reviews | AURs are intended to improve the patient's knowledge and use of the appliance they are using. They can only be conducted with consent by the user. Must be conducted by a specialist nurse - working on behalf of the appliance contractor or pharmacy contractor - or by a pharmacist. | £28 per AUR conducted at the premises of the contractor. £54 per AUR conducted at user's home. If more than one AUR conducted in the same location within a 24-hour period, £54 for the first AUR and £28 for each subsequent AUR. |
In addition DACs receive an infrastructure payment in the same way Pharmacy Contractors receive a practice payment. The table below shows how this will be paid to DACs and will be based on fee per item dispensed. DACs will receive the infrastructure payment which does not have to be claimed but which will be paid automatically.
For items dispensed within the first band, all DACs will receive a fixed monthly payment of £150.00 and in the remaining bands; DACs will be paid a fee per each Part IX prescription item dispensed each month
| Band identifier | No. of Part IX prescription items dispensed in one month | Infrastructure payment |
|---|---|---|
| A | 1 - 10 | £ 150.00 fixed |
| B | 11 - 1,000 | £ 13.60 per item |
| C | 1,001 - 35,000 | £ 2.40 per item |
| D | 35,000 + | £ 2.30 per item |