National enhanced service - minor injury services
2 May 2003 (updated January 2007)
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 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.
2. This specification sets out an in-hours service. Where it is considered that a 24 hour/7 day service would be required, PCOs should modify the specification and pricing accordingly.
Background
3. This NES recognises the need for a consistent approach to rewarding GPs equitably for providing minor injury services within their own practice.
4. This service will be commissioned in the context of reforming emergency care services and reducing pressure on A&E departments.
5. Outside the conurbations and those towns having a District General Hospital based Accident & Emergency service, local general practitioners for historical and professional ethical reasons have had to provide Minor Injury Services (MIS) either at their surgery premises or in a Minor Injury Unit (MIU) usually attached to a community hospital.
6. Professional consensus indicates that injuries and wounds over 48 hours old should usually be dealt with through normal primary care services as should any lesion of a non-traumatic origin. By definition such cases are usually the self-presenting "walking wounded" and ambulance cases are not usually accepted except by individual prior agreement between the doctor and the attending ambulance personnel.
7. The following list gives guidance on the types of injuries and circumstances that lead to the use of Minor Injury Services and is not comprehensive:
(i) lacerations capable of closure by simple techniques (stripping, gluing, suturing)
(ii) bruises
(iii) minor dislocations of phalanges
(iv) foreign bodies
(v) non-penetrating superficial ocular foreign bodies
(vi) following advice to attend specifically given by a general practitioner
(vii) following recent injury of a severity not amenable to simple domestic first aid
(viii) following recent injury where it is suspected stitches may be required
(ix) following blows to the head where there has been no loss of consciousness
(x) recent eye injury
(xi) partial thickness thermal burns or scalds involving broken skin:
(a) not over 1 inch diameter
(b) not involving the hands, feet, face, neck, genital areas
(xii) foreign bodies superficially embedded in tissues
(xiii) minor trauma to hands, limbs or feet.
Service outline
8. This national enhanced service will fund:
(i) initial triage including immediately necessary clinical action to staunch haemorrhage and prevent further exacerbation of the injury
(ii) history taking, relevant clinical examination, documentation
(iii) wound assessment to ascertain suitability for locally based treatment and immediate wound dressing and toilet where indicated
(iv) appropriate and timely referral and/or follow up arrangements
(v) adequate facilities including premises and equipment, as are necessary to enable the proper provision of minor injury services including facilities for cardiopulmonary resuscitation
(vi) registered nurses. To provide care and support to patients undergoing minor injury services.
(vii) maintenance of infection control standards
(viii) information to patients on the treatment options and the treatment proposed. The patient should give consent for the procedure to be carried out and the completed consent form should be filed in the patient’s lifelong medical record.
(ix) maintenance of records of all procedures
(x) audit of minor injury list work at regular intervals.
9. Patients in the following categories are not appropriate for treatment by the Minor Injury Service but the enhanced service covers the appropriate referral of these patients elsewhere:
(i) 999 call (unless attending crew speak directly to the doctor)
(ii) any patient who cannot be discharged home after treatment
(iii) any patient with airway, breathing, circulatory or neurological compromise
(iv) actual or suspected overdose
(v) accidental ingestion, poisoning, fume or smoke inhalation
(vi) blows to the head with loss of consciousness or extremes of age
(vii) sudden collapse or fall in a public place
(viii) penetrating eye injury
(ix) chemical, biological, or radioactive contamination injured patients
(x) full thickness burns
(xi) burns caused by electric shock
(xii) partial thickness burns over 3cm diameter or involving:
(a) injuries to organs of special sense
(b) injuries to the face, neck, hands, feet or genitalia
(xiii) new or unexpected bleeding from any body orifice if profuse
(xiv) foreign bodies impacted in bodily orifices, especially in children
(xv) foreign bodies deeply embedded in tissues
(xvi) trauma to hands, limbs or feet substantially affecting function
(xvii) penetrating injuries to the head, torso, abdomen
(xviii) lacerating/penetrating injuries involving nerve, artery or tendon damage.
Accreditation
10. Doctors providing minor injury services would be expected to:
(i) have either current experience of provision of minor injury work, or
(ii) have current minor injury experience, or
(iii) have recent accident & emergency experience, or
(iv) have equivalent training which satisfies relevant appraisal and revalidation procedures.
11. Doctors carrying out minor injury services must be competent in resuscitation and, as for other areas of clinical practice, have a responsibility for ensuring that their skills are regularly updated. Doctors carrying out minor injury activity should demonstrate a continuing sustained level of activity, conduct audit data and take part in appropriate educational activities.
12. Nurses assisting in minor injury procedures should be appropriately trained and competent taking into consideration their professional accountability and the Nursing and Midwifery Council (NMC) guidelines on the scope of professional practice.
13. 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 shall be deemed professionally qualified to do so.
Costs
14. In 2003/04 each practice contracted to provide this service will receive an annual retainer of £1,000 plus £50 per patient episode. The PCO will agree with the provider the basis on which the NES will be funded in light of the procedures to be carried out and the volume to be carried out, including setting an upper cap. This should be reviewed by the PCO and the practice when the practice is approaching the number of procedures set by the upper cap. The PCO may wish to consider the impact that the practice’s service provision is having on the reduction of demand on other services. These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06.
15. All drugs, dressings and appliances will be funded and supplied separately by the PCT.