National enhanced service Provision of near-patient testing Introduction
1. All practices are expected to provide essential and those additional services they are contracted to
provide to all their patients. This enhanced service specification outlines the more specialisedservices to be provided. The specification of this service is designed to cover the enhanced aspectsof clinical care of the patient all of which are beyond the scope of essential services. No part ofthe specification by commission, omission or implication defines or redefines essential oradditional services. Background
2. The treatment of several diseases within the fields of medicine, particularly in rheumatology, is
increasingly reliant on drugs that, while clinically effective, need regular blood monitoring. This isdue to the potentially serious side-effects that these drugs can occasionally cause. It has beenshown that the incidence of side-effects can be reduced significantly if this monitoring is carriedout in a well-organised way, close to the patient’s home.
3. The near patient testing service is designed to be one in which:
therapy should only be started for recognised indications for specified lengths of time
maintenance of patients first stabilised in the secondary care setting should be properlycontrolled
the need for continuation of therapy is reviewed regularly
the therapy is discontinued when appropriate
the use of resources by the National Health Service is efficient. Service outline
4. This national enhanced service will fund:
a shared care drug monitoring service in respect of the following specified drugs:
This could also cover all ‘amber’ lists drugs where shared care is appropriate
a register. Practices should be able to produce and maintain an up-to-date register of all shared care drug monitoring service patients, indicating patient name, date of birth and the indication and duration of treatment and last hospital appointment call and recall. To ensure that systematic call and recall of patients on this register is taking place either in a hospital or general practice setting education and newly diagnosed patients. To ensure that all newly diagnosed / treated patients (and / or their carers when appropriate) receive appropriate education and advice on management of and prevention of secondary complications of their condition. This should include written information where appropriate continuing information for patients. To ensure that all patients (and/or their carers and support staff when appropriate) are informed of how to access appropriate and relevant information individual management plan. To ensure that the patient has an individual management plan, which gives the reason for treatment, the planned duration, the monitoring timetable and, if appropriate, the therapeutic range to be obtained professional links. To work together with other professionals when appropriate. Any health professionals involved in the care of patients in the programme should be appropriately trained referral policies. Where appropriate to refer patients promptly to other necessary services and to the relevant support agencies using locally agreed guidelines where these exist record keeping. To maintain adequate records of the service provided, incorporating all known information relating to any significant events e.g. hospital admissions, death of which the practice has been notified training. Each practice must ensure that all staff involved in providing any aspect of care under this scheme have the necessary training and skills to do so annual review. All practices involved in the scheme should perform an annual review which could include:
brief details as to arrangements for each of the aspects highlighted in the NES
details as to any computer-assisted decision-making equipment used andarrangements for internal and external quality assurance
details as to any near-patient testing equipment used and arrangements forinternal and external quality assurance
details of training and education relevant to the drug monitoring service
details of the standards used for the control of the relevant condition
assurance that any staff member responsible for prescribing must havedeveloped the necessary skills to prescribe safely.
5. It is a condition of participation in this NES that practitioners will give notification, in addition to
their statutory obligations, within 72 hours of the information becoming known to him/her, tothe PCO clinical governance lead of all emergency admissions or deaths of any patient covered
under this service, where such admission or death is or may be due to usage of the drug(s) inquestion or attributable to the relevant underlying medical condition. Accreditation
6. Those doctors who have previously provided services similar to the proposed enhanced service
and who satisfy at appraisal and revalidation that they have such continuing medical experience,training and competence as is necessary to enable them to contract for the enhanced service shallbe deemed professionally qualified to do so.
7. In 2003/04 each practice contracted to provide this service will receive:
where sampling requires a domiciliary visit
to a housebound patient on or behalf of the
fee would be paid for each separate address
These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06.
Drug: Penicillamine PROTOCOL NUMBER: 04 Indication:Rheumatoid arthritis General guidance
1. This protocol sets out details for the shared care of patients taking PENICILLAMINE. Background
2. Penicillamine is an effective second-line drug used in the treatment of rheumatoid arthritis. Dosage Regimes
3. 125mg daily, increasing by 125mg increments every 4 weeks to 500mg daily if tolerated. Some
patients respond to a lower dose, occasionally 750mg a day is required. If no response in 1 yeardiscontinue treatment. Not to be taken within 2 hours of food. Monitoring
every 2 weeks for 8 weeks, 1 week after any dosage increment, monthly thereafter. Drug: Sulphasalazine PROTOCOL NUMBER: 05 Indication: Rheumatoid Arthritis General guidance
1. This protocol sets out details for the shared care of patients taking SULPHASALAZINE.
2. Sulphasalazine (Salazopyrin) is widely use for the long term treatment of rheumatoid arthritis. There
are two preparations in use, Salazopyrin EN, (oval, film coated) and generic sulphasalazine (round,uncoated). The former is considered to have less GI side effects. Dosage Regimes
3. 500mg daily increasing by 500mg weekly increments to a maximum of 1g bd, if tolerated. Some
patients may respond to a lower dose. Treatment may be continued indefinitely, the usual reason forstopping being loss of benefit. Sulphasalazine is sometimes co-prescribed with other anti-rheumaticagents. Monitoring
at 3, 6 & 12 weeks, every 3 months thereafter.
Urgent FBC if patient complains of intercurrent illness during initiation of treatment. Drug: Sodium Aurothiomalate (Myocrisin) PROTOCOL NUMBER: 08 Indication: Rheumatoid Arthritis General guidance
1. This protocol sets out details for the shared care of patients taking SODIUM AUROTHIOMALATE.
2. Sodium aurothiomalate is a slow-acting drug effective in controlling disease activity in 60-70% of
patients with rheumatoid arthritis. Improvement can be expected after 2-3 months (400-600 mgtotal dose), and in the absence of toxicity gold injections can be continued indefinitely.
3. 10mg IM test dose then 50mg one week later fol owed by 50mg weekly to a total dose of 500mg. If
there is a clinical response, the frequency of injections can be reduced to every 2 weeks up to a totaldose of 1g. In the absence of an improvement continue at 50mg weekly to a total dose of 1g. Ifafter 1g there is clinical improvement, reduce the frequency of injections to every 3-4 weeks. If noresponse after 1g total dose stop gold.
4. Dose record cards are available from the hospital and must be carefully maintained. Monitoring
(ESR/CRP is useful to assess response to therapy)
Drug: Auranofin PROTOCOL NUMBER: 09 Indication: Rheumatoid Arthritis General guidance
1. This protocol sets out details for the shared care of patients taking AURANOFIN.
2. Auranofin in general is less effective, less toxic and slower to induce a remission than intramuscular
gold, and clinical benefit may not become apparent for up to 3-6 months. Dosage Regimes
3. 6mg daily - either 6mg before breakfast, or 3mg bd before meals. Monitoring Drug: Methotrexate PROTOCOL NUMBER: 11 Indication: Rheumatoid Arthritis, Psoriasis General guidance
1. This protocol sets out details for the shared care of patients taking METHOTREXATE.
2. Methotrexate is an effective second-line drug used in the treatment of rheumatoid arthritis and
psoriasis. It has both immunosuppressant and anti-inflammatory effects. Dosage Regimes
3. Initially 5mg to 7.5mg orally once weekly, maintenance dose 7.5 to 12.5mg per week. Monitoring
weekly for 6 week initially then monthly, any dosage increase should be fol owed byan FBC one week later
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