National enhanced service - more specialised services for patients with multiple sclerosis
2 May 2003 (updated November 2003)
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.
Background
2. Evidence shows that:
(i) multiple sclerosis (MS) is the most common cause of chronic neurological disability in young adults, with a prevalence of about 1 in 1000. About 50 per cent of patients are unable to walk without assistance 15 years after onset. (1) Overall, MS affects approximately 85,000 people in the United Kingdom, and is 50 per cent more common in women than men.
(ii) in the majority of cases, MS is relapsing and remitting. However, around 40 per cent of people with MS develop secondary progressive MS, which can cause disability, poor co-ordination and a range of other symptoms, including deterioration in sight. Around 15 per cent of MS sufferers have the primary progressive, or chronic progressive, form of the disease. They will experience rapidly worsening symptoms and progressive disability from the start, and are likely to have a reduced life span. (2)
Aims
3. The aim of the scheme is to address proactively the physical health care needs of patients with MS, by ensuring they receive rounded health care and support. Where appropriate, the scheme should encourage the primary care team to work closely with the patient’s carer(s), and to encourage closer interaction with other support services.
Service outline
4. This national enhanced service will fund:
(i) production and maintenance of an up-to-date register of all patients with MS and, where appropriate, their carers. This will be used as an audit and communication tool within the practice
(ii) establishing a lead contact/co-ordinator. The primary health care team will establish a nominated co-ordinator to liaise closely with external services to develop a practice-based plan identifying roles and responsibilities. As appropriate, this will mean liaison with specialist neurology, physiotherapy, urology, speech therapy and occupational therapy services
(iii) regular assessment. This should be used to review physical symptoms; review the effect of medication, including use of steroids, painkillers, antidepressants, and drugs to relieve spasticity; and to check on the patient’s broader health needs, for example whether the patient has had a recent eye test
(iv) training. Members of the primary health care team will be committed through continued practice and personal development and through the establishment of a practice reference resource. The aim of such training would be to cover:
(a) the nature of MS
(b) making the diagnosis
(c) common complications
(d) symptom control
(e) monitoring
(f) when to refer a patient to a specialist
(v) carer support. Carers should be supported, kept fully informed and encouraged and educated to play as full a role in the patient’s care as they wish. Where appropriate, they should be regarded as an integral part of the team
(vi) personal health plans. Each patient being monitored under the NES should have a personal health plan. This plan should include diagnosis, disease type, investigations, current treatments, social support etc. This plan should be reviewed and updated regularly, where appropriate, involving clinical and social support agencies
(vii) liaison with secondary care and social services. Where appropriate to do so, and with the patient’s consent, it is expected that the practice would regularly discuss the ongoing care of each patient with any other relevant agency involved. This will help to ensure “joined-up planning” to meet all of the patient’s needs. It will help to reduce duplication of effort and give the patient a first point of contact for concerns or questions
(viii) All practices providing the service should perform an annual multi-disciplinary review which could include:
(a) an audit of the MS patient register, including a check on complications
(b) a report on the existence of an appropriate care package
(c)an audit of the effectiveness of symptom control techniques
(d) feedback from patients on the MS register and their carers using a standardised questionnaire.
Accreditation
5. Those doctors who have previously provided services similar to this 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
6. In 2003/04 each practice contracted to provide this service will receive £90 - £140 per patient per annum paid quarterly in arrears. These prices will be uprated by 3.225 per cent in 2004/05 and again in 2005/06.
(1) Polman CH, Uitdehaag BMJ. Regular review: Drug treatment of multiple sclerosis. BMJ 2000; 490-494.
(2) MS Society.
(3) Sadovnik AD, Remick RA, Allen J, Swartz E, Yee IML, Eisen K, et al. Depression and multiple sclerosis. Neurology 1996; 46: 628-32
(4) Smith CR, Aison MC, Scheinberg L. Symptomatic management of Multiple Sclerosis. Multiple Sclerosis 1986: 166-83.