Service Level Agreement

Between
Wirral Primary Care Trust
And
NAME
For the provision of a

Accredited Optometrists Cataract Pre-Operative

Referral Assessment Service
February 2011

Service Level Agreement Cataract Pre-Operative Referral Assessment Service

Contents
Clause
Number

Page
Number

Contents Page
1. Parties to the Agreement
2. Purpose of the Agreement
3. Agreement Term
4. Obligations of the Parties to this Agreement
5. Representatives
6. Services and Objectives
7. Fees and Payments
8. Monitoring and Information Requirements
9. Complaints
10. Serious Untoward Incidents
11. Patient Safety Incidents
12. Risk Management
13. Service Monitoring and Quality
14. Demand Management
15. Confidentiality and Data Storage (Caldicott)
16. Discrimination
17. Dispute Resolution
18. Termination
19. Consequences of Termination
20. Variation
21. Notices
22. Waiver
23. Insurance
24. Indemnity
25. Staff
26. Prevention of Corruption
27. Force Majeure
28. Access to services
29. Equality and Diversity
30. Freedom of Information
31. Representation and Warranties
32. Entitlement to Contract
33. Signatories
Appendix 1: Service Specification
Appendix 2: Map of Medicine Pathway
Appendix 3: Referral Proforma

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3
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6
7
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8
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11
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12
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13
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16 - 21
22 - 27
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Service Level Agreement Cataract Pre-Operative Referral Assessment Service

Service Level Agreement for the provision of Cataract Pre-Operative Referral Assessment
Service.
1.

Parties to the Agreement

1.1 Wirral Primary Care Trust whose principal office is at Old Market House, Hamilton Street,
Birkenhead, Wirral, CH41 5FL, and
1.2 NAME, ADDRESS
2.

Purpose of the agreement

2.1 The agreement is for the provision of a Cataract Pre-Operative Referral Assessment
Service within Wirral PCT.
3.

Agreement Term

3.1 This is a fixed term agreement that shall operate for the period 1 st April 2011 to 31st March
2013 (the term) and will terminate on the expiry of the Term but subject to early termination
should the provider not comply with the obligations of this agreement as stated in clause 18.
3.2 If both partners mutually agree to the extension of the term of the agreement beyond the
expiry date, the written notice to extend the service must be served one calendar month prior
to the expiry date.
4.

Obligations of the Parties to this Agreement

4.1 The Provider:

4.1.1 agrees to perform the obligations set out in the Service Specification (Appendix 1) and
in accordance with the provision and Term of this agreement.
4.1.2 acknowledges that the designated funds shall be used for the specific function of this
SLA
4.1.3 shall not sub contract any of the functions within the provision of this agreement unless
expressly allowed to by NHS regulations and with the written consent of the PCT.
4.1.4 will ensure any protocols or guidance issues identified by the Provider in relation to the
services delivered are communicated to and followed by all relevant staff.
4.1.5 agree to provide any necessary authorisations to auditors, both internal and external
and to disclose any information necessary for the proper conduct of audit work within the
PCTs organisation.
4.1.6 agrees to comply with the performance monitoring and information requirements laid
out in clause 8.
4.1.7 shall use reasonable endeavors to avoid creating any circumstance which may
undermine patient or public confidence in the services of either the PCT or the Provider, or
otherwise damage the profile and integrity of the other party or this agreement.
4.1.8 shall keep up to date with appropriate legislation and comply with all legislation relevant
to the operation of the organisation.
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4.1.9 shall provide at its own expense all staff, equipment, tools, appliances, materials or
items required for the provision of the Services to the contract standard which excludes initial
set up costs/equipment.
4.1.10 agrees that the responsibility for cover for long term sickness, maternity, paternity,
adoptive and other long term leave is the responsibility of the Provider.
4.2 The PCT:
4.2.1 agrees to make payments to the Provider in accordance with the provisions of this
agreement provided that the Provider complies with its obligations.
4.2.2 is able to review its funding for subsequent periods after the expiration of the Terms of
this Agreement.
4.2.3 reserves the right to review the funding based upon performance of the Provider
including but not limited to the non provision of the activities outlined within this agreement.
4.2.4 will inform the Provider, with a reasonable period of notice, of service developments,
timetable or other changes that impact on the delivery of services under this agreement.
4.2.5 will ensure that any protocols or guidance issues identified by the Provider in relation to
the services delivered are communicated to and followed by the relevant staff.
4.2.6 agrees to provide any necessary authorisations to Auditors, both internal and external,
to disclose any information necessary for the proper conduct of audit work within the
Providers organisation.
4.2.7 shall use reasonable endeavors to avoid creating any circumstance which may
undermine patient or public confidence in the services of the of the PCT or the Provider, or
otherwise damage the profile and integrity of the other party or this agreement.
5.

Representatives

5.1 For the terms of this agreement the Provider shall appoint a Provider Contract
Representative who shall be the key point of contact to whom all queries and day to day
communications regarding the operation of this agreement should be addressed.
5.1.1 The Provider Contract Representative is:
NAME
ADDRESS
5.2 For the terms of this agreement the PCT shall appoint a Commissioner Contract
Representative who shall be the key point of contact to whom all queries and day to day
communications regarding the operation of this agreement should be addressed.
5.2.1 The Commissioning Contract Representative is:
Glenn Coleman
Deputy Director, Primary Care
NHS Wirral
Old Market House
Hamilton Street
Birkenhead
Wirral
Service Level Agreement Cataract Pre-Operative Referral Assessment Service

CH41 5FL
6.

Services and Objectives

6.1 The functions and activities to be provided under this agreement are outlined in detail in
the Service Specification (Appendix 1).
7.

Fees and Payment

7.1 The PCT shall make payments on a monthly basis in accordance with invoices received
based on the number of assessments undertaken. The invoice will be incorporated into the
Monitoring and Information Requirements spread sheet at 8.1.
7.2 The invoices will be produced by the Provider and sent to the PCT monthly, in arrears.
Such an invoice to contain details of a number of assessments the Provider has carried out
during the previous month, together with its calculation of the amount of fees payable to it.
The Provider is to check, sign and submit the invoice to the PCT.
7.3 The PCT will pay within 30 days of receipt of the signed invoice for all invoices submitted
by the Provider in accordance with this contract.
7.4 The PCT shall be entitled to deduct part or all of the fees payable to the Provider under
this clause in circumstances where the Provider has failed to provide the Services in
accordance with the provisions of this Contract and providing the PCT has given prior written
notice to the Provider of its intention to deduct part or all of the fees payable.
7.5 If:
7.5.1 The PCT disputes any or part of the invoice calculated in accordance with sub-clause
7.2; or
7.5.2 The Provider disputes an amount which the PCT has deducted pursuant to its rights
under sub-clause 7.4. then in the case of sub-clause 7.5.1, the undisputed amount of the
invoice shall be paid by the PCT in accordance with sub-clause 7.2. In relation to both subclauses 7.5.1 and 7.5.2 the parties shall use reasonable endeavors to resolve the dispute
within 20 working days. If they fail to resolve it then either party may refer to clause 17.
Following resolution of the dispute, any amount agreed or determined to have been payable
shall now be paid.
7.6 Fees will be reviewed by the PCT at the expiry of the Initial Term and any proposed
changes to the amount of fees shall be dealt with in the Renewal notice.
7.7 The only sums payable by the PCT for the provision of services shall be the fees as set
out in this clause.
7.8 The fees will be subject to annual negotiation which may not lead to an increase and any
increase would not exceed National NHS uplift except under very exceptional circumstances.
The effective date of any increase would be 1st April each year which runs from April to the
following March.
7.9 The initial workshop regarding participation and accreditation will be facilitated by the
PCT.
8.

Monitoring and Information Requirements

Service Level Agreement Cataract Pre-Operative Referral Assessment Service

8.1 The Provider shall provide the information specified within this clause and within Quality
Standards and Performance Indications as per the service specification (Appendix 1).
8.1.1 The following activity data is required as a minimum by the Provider:
Date of referral
NHS number (where available)
Patient name
Patient address
Patient GP Practice
Date of consultation
Optometrist Practice
Clinical reason for Cataract Assessment
Clinical outcome of consultation
8.1.2 The information / invoice is to be provided on a monthly basis on a spreadsheet and
emailed to confidential PCT email address to be password protected or a secure postal
system (recorded delivery) to the PCT at the address below:
Glenn Coleman
Deputy Director, Provider Services
NHS Wirral
Old Market House
Hamilton Street
Birkenhead
Wirral
CH41 5FL
8.1.3 If Information is not reported on a monthly basis, there will be no penalty for the first
month in which the information is not provided. However, subsequent missing monthly
activity will be subject, at the discretion of Wirral PCT to withhold 10% of the monthly
payments.
8.1.4 Subject to clauses 8.1.4.1 and 8.1.4.2, the funds withheld in clause 8.1.3 will be
released to the Provider within 10 operational days of receipt of the information, as long as.
8.1.4.1 the information provided is fit for purpose and meets the criteria laid out in
clause 8.1.1.
8.1.4.2 the information is received within 3 calendar months of the date it was
originally due.
8.1.5 Activity will be jointly monitored by the Provider and the PCT within the Service
Specification.
8.1.6 Activity will be measured on a monthly basis using the following criteria:
Number of patients seen
Where patients are seen
Source of referral
Outcome of assessment
Details of over/under performance
8.2 During the contract period, the PCT may inspect and examine the provision of the
Services being carried out at the location with appropriate notice. The Provider shall provide
to the PCT all such facilities as required for inspection.

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8.3 If the performance of any part of any Service by the Provider is found to be defective,
incomplete or performed in a negligent manner the PCT will inform the Provider of this
problem. The Provider shall at its own expense re-perform the services in question within
such time as the PCT may reasonably specify failing which the PCT shall be entitled to
procure performance of the defected services from a third party or to execute the task in
question itself. If the cost to the PCT of executing or procuring such services exceeds the
amount that would have been payable to the Provider for such services; the excess shall be
paid by the Provider to the PCT on demand in addition to any other sums payable by the
Provider to the PCT in respect of the breach of contract.
9.

Complaints

9.1 The PCT and the Provider shall maintain a complaints procedure compliant with all Law
(including any NHS Complaints Regulations in force) applicable to it and shall provide the
other Parties with such details relating to that complaints procedure as required.
9.2 The Provider shall inform patients and appropriate family members and carers known to
the Provider that they are entitled to use the complaints procedure and shall make details of
it and any relevant Independent Advocacy Service available to the patient, a family member
or other carers on request.
9.3 All complaints received by the Provider in writing shall be acknowledged in writing within
the period of 3 working days beginning with the day on which the complaint was received or,
where that is not practicable, as soon as reasonably possible. All complaints shall be
properly investigated by the Provider and the results of such investigations shall be notified
to the patient.
9.4 Any complaint received by the PCT as a result of the above will be investigated by the
PCT in accordance with the PCTs complaints procedure.
10.

Serious Untoward Incidents (SUIs) Reporting

10.1 The Provider shall promptly provide to the Commissioning representative, a full copy of
any notification made by the Provider to the CQC or Commission for the Social Care
Inspection or any successor body where such notification directly or indirectly concerns any
patient.
10.2 This clause shall survive the termination or expiry of this agreement. Any serious
incidents, near misses or complaints will be reported on a monthly basis in accordance with
this clause and will be verbally reported to the PCT Commissioning Manager within one
working day.
11.

Patient Safety Incidents

11.1 With regard to Patient Safety Incidents, the Provider will:

11.1.1 report to Wirral PCT who on their behalf will, where required, report patient safety
incidents to the National Patient Safety Agency (NPSA) or any successor organisation or
system.
11.1.2 support the PCT to implement NPSA guidance.
11.1.3 have local risk management procedures in place to analyse and learn from patient
safety incidents.
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12.

Risk Management

12.1 The Provider and the PCT will work together to manage the risks relating to this
agreement and shall have in place appropriate systems for risk identification, eradication and
mitigation. Should an incident arise staff will bring it to the attention of the appropriate officers
of both parties using agreed incident reporting processes.
13.

Service Monitoring and Quality

13.1 In addition to any more specific obligations imposed by the terms of the Contract, it shall
be the duty of the Provider to provide the Services to the Contract Standard which in all
respects shall be to the satisfaction of PCT.
13.2 During the Contract Period, the PCT may inspect and examine the provision of the
Services being carried out at the Location with appropriate notice. The Provider shall provide
to PCT all such facilities as PCT may require for such inspection and examination.
13.3 If the performance of any part of any Service by the Provider (or members of his staff or
sub-contractors) is found to be defective, incomplete or performed in a negligent manner the
PCT will inform the Provider of this problem. The Provider shall at its own expense reperform the Services in question (without additional remuneration therefore) within such time
as the PCT may reasonably specify failing which the PCT shall be entitled to procure
performance of the defective Services from a third party or to execute the tasks in question. If
the cost to the PCT of executing or procuring such Services exceeds the amount that would
have been payable to the Provider for such Services, the excess shall be paid by the
Provider to the PCT on demand in addition to any other sums payable by the Provider to the
PCT in respect of the breach of Contract.
13.4 The Provider will adopt a process for significant or adverse event audit, sharing the
outcomes and follow-up actions with the PCT and co-operating with the PCT instigated
audits when requested. An audit will also be carried out annually.
13.5 The Provider agrees that it will only issue patient literature previously approved by the
PCT to its Patients. This will normally be edited and approved by the Plain Language
Commission or other editing service.
13.6 The Provider shall also comply with the standards and recommendations from time to
time:
13.6.1 Technology Appraisals, Clinical Governance and Clinical Interventions and guidance
issued by the National Institute for Health and Clinical Excellence (or any successor)
13.6.2 Issued by the UK National Screening Committee and the National Specialist
Commissioning Advisory Group (or any successors) and agreed in writing between the PCT
and the Provider.
3.6.3 Issued by any relevant professional body and agreed in writing between the PCT and
the Provider; and such other quality standards and recommendations from time to time
agreed in writing between the PCT and the Provider; and all such standards and
recommendations, when agreed must be added to Quality standards and performance
indicators.
14.

Demand Management

Service Level Agreement Cataract Pre-Operative Referral Assessment Service

14.1 The PCT and the Provider have a mutual responsibility to manage demand for the
services.
14.2 The Provider agrees to ensure that its agents and employees shall adhere to any
referral and treatment protocols.
15.

Confidentiality and Date Storage (Caldecott)

15.1 The PCT and Provider acknowledge that their respective duties under the Data
Protection Act 1998 and the Freedom of Information Act 2000 and hereby confirm they will
comply with their obligations and duties under the said Acts and shall give all reasonable
assistance to each other where appropriate or necessary to comply with any obligations
arising under the said Acts.
15.2 All parties will maintain appropriate confidentiality regarding information that is
proprietary to the other party consistent with the context of shared working. In addition, the
Provider will ensure that appropriate written confidentiality clauses are present in all of its
staff contracts so that its staff are obliged to preserve Patient confidentiality at all times.
15.3 The Provider must not use Patient information obtained as a result of the provision of
the Services under this Contract for marketing purposes or commercial activities.
15.4 Where, for the purposes of delivering the Services, it is necessary for the Provider to
hold patient identifiable information (i.e. information that is subject to NHS Rules on
protection and disclosure under the supervision of a named Caldecott Guardian on behalf
of the PCT), it shall not disclose such documentation from which the patient identifiable
information has originated to any party except as may be permitted in sub-clause 15.5.
15.5 The Provider may disclose patient identifiable information for proper purposes where
such disclosure is supervised by and given with the consent of the Caldecott guardian of the
PCT. This consent may be given in general or specific terms, but cannot authorise any
greater degree of disclosure than would be permitted under the Caldecott arrangements of
either party.
16.

Discrimination

16.1 The PCT and the Provider shall not discriminate unlawfully within the meaning and
scope of any Law, enactment, order, regulation, or similar instrument relating to
discrimination (whether relating to race, gender, disability, religion or otherwise) in
employment or performance of the services and each of them shall take all reasonable steps
to ensure observance of this clause.
17.

Dispute resolution

17.1 Both parties to this Contract will use all reasonable endeavors to resolve any dispute or
differences between them in accordance with this Clause.
17.2 During any dispute, including a dispute as to the validity of the Contract, it is mutually
agreed that the Provider shall continue its performance of the provisions of the Contract
(unless PCT requests in writing that the Provider does not do so). The PCT will pay the
Provider in accordance with the provisions of clause 7 as if the contract were valid.
17.3 Where one party considers that the other party has not performed its obligations under
this Contract, that party will give written notice to the other party specifying the nature of the
Service Level Agreement Cataract Pre-Operative Referral Assessment Service

breach and requiring the other party to attend a meeting with the party serving the notice at a
mutually convenient time but in any event within four weeks after the date of such written
notice.
17.4 Unless another course of action (such as but not limited to mediation) is agreed
between the parties at the meeting referred to in sub-clause 17.3, the party which was in
receipt of the notice served pursuant to sub-clause 17.3 shall remedy the breach referred to
in that notice within twelve weeks after the date of the meeting.
17.5 Where non-performance has not been rectified within the timescale set out at subclause 17.4 (or such other timescale as may be agreed between the parties), the other party
will have the right to terminate the Contract in accordance with clause 18.
17.6 In circumstances where the notice issued pursuant to sub-clause 17.3 relates to a
breach, the PCT may require the Provider to suspend the provision of the Services whilst the
Dispute Resolution Procedure is ongoing until such date the Provider has remedied the
breach to the reasonable satisfaction of the PCT.
18.

Termination

18.1 Either Party may terminate this Contract on three months prior written notice.
18.2 The PCT may terminate this Contract on one months written notice to the Provider if:
18.2.1 the Provider is in material breach of an obligation under this Contract and the breach
is not capable of remedy in accordance with the Dispute Resolution Procedure;
18.2.2 the Provider is in material breach of an obligation under this Contract, which was
capable of being remedied but which has not been remedied in accordance with the Dispute
Resolution Procedure; or
18.3 The PCT may terminate this Contract with immediate effect if:
18.3.1 the Provider becomes insolvent or otherwise ceases to be capable of providing the
Services.
18.4 The Provider may terminate this Contract on three (3) months written notice to the PCT
if:
18.4.1 the PCT is in material breach of an obligation under this Contract and the breach is
not capable of remedy in accordance with the Dispute Resolution Procedure;
18.4.2 the PCT is in material breach of an obligation under this Contract, which was capable
of being remedied but which has not been remedied in accordance with the Dispute
Resolution Procedure; or
18.4.3 the PCT has failed to pay by the due date any sum properly due and owing by it to the
Provider under this Contract and such non-payment continues unremedied and is not the
subject of a dispute at the expiry of a period of ninety (90) days following the date of the letter
of notification by the Provider of such non-payment to the PCT.
18.4.4 In circumstances where the PCT has issued a termination notice to the Provider as a
result of one of the circumstances in sub-clause 18.2.1 or 18.2.2 having occurred, the PCT
may require the Provider to immediately suspend its provision of the Services during the
notice period in circumstances where:
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18.4.5 the breach relates to a complaint in respect of a serious alleged incident or a serious
clinical governance issue;
18.4.6 it is alleged that the Provider has been falsifying records/claims under this Contract;
and/or
18.4.7 the Provider or its Accredited Optometrist(s) is alleged to have committed a serious
professional misconduct and/or is under investigation by the General Optical Council.
18.5 The PCT may withdraw the termination notice in circumstances where an independent
investigation has determined that the Provider and/or its Qualified Personnel are found not to
have committed the alleged incident/breach as set out in sub-clauses 18.2.1 to 18.2.2 above.
19.

Consequences of Termination

19.1 If any party terminates this contract prior to the expiry of the Initial Term or the Renewal
Term:
19.1.1 The PCT shall pay to the Provider within 20 working days of the termination date and
all arrears of Fees properly due to and payable under the provisions of the contract.
19.1.2 The Provider shall pay to the PCT within 20 working days of the termination date an
amount equivalent to the proportion of any fees already paid by the PCT to the Provider but
which relates to a period which falls after the termination date.
19.1.3 The Provider must within 20 working days of termination return all equipment unused
consumables, promotional literature, etc provided by the PCT.
20.

Variation

20.1 The PCT reserves the right to vary any part of the contract at any time as a result of any
Act of Parliament or direction by Central Government or outcome of a review or audit carried
out by the PCT as a result of significant changes having occurred in national, regional and
local circumstances which have the potential of having a significant impact on demand,
provided that 3 months notice has been given in writing to the Provider in respect of such
variation.
20.2 In the event that either party requires a change to the service specification and/or the
terms of this agreement, the party shall immediately inform the other party in writing the
details relating to the service change.
20.2.1 Such changes shall not come into effect until a written acceptance of the proposed
variation, detailing the consequential amendments, is signed by both parties Contract
representatives.
21.

Notices

21.1 Any notices required to be given under this agreement must be in writing and delivered
to the Commissioning/Provider representative by personal delivery, post (special delivery),
electronic mail or facsimile.
21.1.1 Notices delivered by hand shall be effective upon delivery.

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21.1.2 Notices given by post shall be effective upon the earliest of actual receipt or 5
operational days after mailing.
22.

Waiver

22.1 The failure by any party to enforce at any time or for any period any one or more terms
and conditions of this agreement shall not be construed as a waiver of its rights at any time
subsequently to enforce such terms or conditions.
23.

Insurance

23.1 The PCT and Provider shall maintain such insurance policies as are appropriate and
adequate having regard to its obligations and liabilities under this agreement.
24.

Indemnity

24.1 The Provider shall indemnify and keep indemnified the PCT against all actions, claims,
damages, demands, proceedings, costs and expenses that may arise in respect to the
provision of the services by the Provider under this contract. This will include injury to or
death of any person, loss of or damage to any property except and to the extent that it arises
out of the negligence of the PCT, its employees or agents.
24.2 In the event of any claim for damages, or of circumstances coming to the notice of the
PCT which might give rise to a claim for damages, which might give rise to a claim for
indemnity from the Provider pursuant to this contract, the PCT shall promptly notify the
Provider thereof in writing, whereupon
24.2.1 immediately, by themselves, their representatives or there insurers, the Provider and
PCT shall consult together without admitting liability, making a payment or generally
engaging in the handling of the claim for damages;
24.2.2 the parties shall seek to act together to reject, defend, minimise or mitigate the claim
for damages and to seek contribution, indemnity or re-imbursement from some other person
as they may agree; and
24.2.3 the handling of the claim for damages shall be delegated to the Provider, his
representatives or his or their insurers and the PCT shall take action in relation to any such
claim for damages as the Provider, his representatives or his or their insurers shall
reasonably require including, without limitation, defending, resisting, compromising or settling
any proceedings or threatened proceedings and appealing any judgement or decision.

25.

Staff

25.1 The appointment of staff, including volunteers, shall be subject to the Providers own HR
and risk assessment process and must include the provision of two satisfactory written
references, one of which should be from a previous/current employer (where applicable).
These should be obtained before individuals commence employment.
25.2 The Providers recruitment process should ensure that all staff and volunteers who work
on a one-to-one basis with vulnerable people and children will be subject to satisfactory
Criminal Records Bureau checks.

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25.3 Staff shall be recruited and employed in accordance with all relevant Equality
Legislation.
25.4 Staff employed for the service shall be suitably qualified.
26.

Prevention of Corruption

26.1 The provider shall not offer, give or agree to give to any person any gift or consideration
of any gift as an inducement or reward for undertaking or agreeing to undertake any action in
relation to obtaining this contract or, for showing or agreeing to show any favour or disfavour
to any patient or perspective patient in relation to the contract.
27.

Force Majeure

27.1 The provider shall not be liable for default arising from circumstances beyond its
reasonable control (such as but not restricted to flood, fire and civil unrest). The funding
bodies shall in such circumstances be entitled to take such action as is deemed necessary to
protect the interests of the service users and make a fair and reasonable adjustment to the
price. In order to reflect any savings in costs that the Provider may make as a consequence
of not funding the service due to the force majeure event provided it is not remedied and the
service is reinstated within 4 months, the PCT shall have the right to terminate this
agreement in accordance with clause 18.
27.2 In the event of a Force Majeure the affected party shall notify the other party as soon as
practicable. The notification shall include details of the Force Majeure Event, including
evidence of its effect on the obligations of the affected party and any action proposed to
mitigate its effect.
28.

Access to services

28.1 The Provider will comply with the Disability Discrimination Act and all related legislation
and have regard to any relevant Government Codes of Practice and guidance.
29.

Equality and diversity

29.1 In providing the service, the Provider shall not unlawfully discriminate against any
groups or individuals on the grounds of race, gender, sexual orientation, age, religious
beliefs, disability or any other circumstances listed in the PCTs Equality and Diversity Policy
and seek to promote equality of opportunity and good relations between people from different
backgrounds. The Provider shall comply with the relevant equality legislation and appropriate
codes of good practice.

30.

Freedom of Information

30.1 Both parties acknowledge that they are subject to the Freedom of Information Act 2000
(FOIA) and the Environmental Information Regulations 2004 (EIR) and either party may be
required to disclose information about this contract to ensure compliance of the PCT with the
FOIA and/or the EIR. Both the Provider and the PCT will act in accordance with the FOIA, the
EIR and the Codes of Practice to the extent that they apply to the Providers Performance
under the contract.
30.2 Where the Provider or the PCT is managing a request, the other shall co-operate and
respond within 5 working days of any request.
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31.

Representations and Warranties

31.1 The PCT, on the one hand, and the Provider, on the other hand hereby represents and
warrants to the other that:
31.1.1 It has full power and authority to enter into this agreement and has taken all
necessary corporate or other action to authorize the execution, delivery and performance
thereof and no restriction on the powers of its officers will be contravened by such execution,
delivery or performance.
31.1.2 All governmental or official approvals and consents have been obtained and are in full
force and effect, and all other actions have been taken, conditions satisfied and things done
in order to enable it lawfully to enter into, comply with its obligations and enforce its rights
under this agreement, and to ensure that this agreement is admissible in evidence in
England.
31.1.3 the execution of the agreement, the performance of obligations and exercise of rights
under them by it does not and will not contravene or conflict with the constitution, Terms of
Authorisation or any law, regulation, contract, charge or undertaking affecting it, any of its
assets or any agreement or document to which it is party or which is binding on it or any of its
assets.
31.1.4 the copies of all documents supplied in the other party or any of its advertisers by or
on its behalf are complete and the contents of them are true.
31.1.5 all information supplied by either party to the other during the award procedure
leading to the execution of this agreement is, to the reasonable knowledge and belief of the
other party, true and accurate in all material aspects and each party is not aware of any
material facts or circumstances which have not been disclosed to the other which would, if
disclosed, be likely to have an adverse effect on a reasonable public sector entitys decision
whether or not to contract with either party substantially on the terms of this agreement.
32.

Entitlement to contract

32.1 This is not an exclusive agreement and the PCT reserves the right to contract with any
persons, firm or company, other than the Provider, for the supply and delivery of similar
services.

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33.

Signatories

In witness whereof the parties have signed this agreement on the date shown below
Date______________________________
Signed by for and on behalf of the Commissioner Wirral Primary Care Trust
Signed __________________________
Name:
Designation
Signed by for and on behalf of the Provider
Signed
Name:
Designation

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Appendix 1 Service Specification

PERFORMANCE REQUIREMENTS SPECIFICATION, QUALITY AND

PRODUCTIVITY
SECTION 1 SPECIFICATION

Care Pathway/Service
Commissioner Lead
Provider Lead
Period

Accredited Optometrists Cataract Pre-Operative Referral

Assessment Service
Glenn Coleman
NAME
1st April 2011-31st March 2013

1. Purpose
1.1 Aims
o To reduce the number and percentage of patients who are referred to hospital but who then
do not proceed to surgery (i.e to increase the conversion rate)
o To reduce unnecessary/inappropriate referrals to hospital (secondary care) eye services
o To free up capacity at secondary care providers in support of 18 week pathways
o To support the PCTs aim to manage referrals and demand.
o To support care closer to home
1.2 Evidence Base
Cataract Pre-Operative Referral Assessment services locally and in other areas have been
shown to be a cost effective way of providing care within the community setting, whilst reducing
the numbers of unnecessary or inappropriate referrals to secondary care for surgery.
1.3 General Overview
The service will provide a Cataract Pre-Operative Referral Assessment Service for Wirral
residents.
NHS Wirral will commission this service from accredited optometrist practices as an enhanced
service, with an SLA to formalise the scheme.
The scheme will support accredited optometrists to conduct appropriate cataract clinical
assessment as per agreed map of medicine pathway and NICE Cataract Surgery Guidelines
2010, Royal College of Ophthalmologists.
1.4 Objectives
This community Cataract Pre-Operative Referral Assessment Service will
o Provide comprehensive screening and diagnosis for people with suspected cataracts.
o Identify dual pathology where present
o Inform patients of the screening outcome and proposed management pathways.
o Provide patients with appropriate information Assess patients suitability and willingness to
undergo cataract surgery, including counseling on the risks and benefits of surgery, in
accordance with the inclusion/exclusion criteria listed in the map of medicine
o Discuss choice of provider with patient.
o Complete and submit the referral form (appendix 3), electronically where possible.
o Maintain a data base and audit trail for all patients entering the scheme

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1.5 Expected Outcomes including improving prevention

Expected outcomes/results
o Where the results are within normal limits and in the absence of significant symptoms, the
patient to be discharged back to the referring optometrist or GP V
o Where there is a cataract diagnosis and patient chooses, referral with appropriate priority to
secondary care.
o Where there is the presence of dual pathology and patient agrees, referral with appropriate
priority to secondary care for a general ophthalmological assessment.
2. Scope
2.1 Service Description
Patient will have attended for routine eye test with an optometrist or will have been seen by a
GP with blurred vision following which suspected ocular cataract has been identified. The patient
will be seen by an accredited optometrist providing the Cataract Pre-Operative Referral
Assessment Service.
2.2 Accessibility/acceptability
All patients with suspected cataracts.
2.3 Whole System Relationships
The service will have links with the following:
Healthcare workers, including GPs and nurse practitioners
Specialist services
Optometrists (accredited and non accredited)
2.4 Interdependencies
It is the responsibility of the providers to ensure that all appropriate details are communicated to
the necessary recipients and appropriate notes are made in the patients records. Patients
clinical progress and post discharge care will be reported to the GP by the Provider.
2.5 Relevant networks and screening programmes
Service provision will be monitored to ensure the maintenance of care standards and that the
service is safe. All members of staff will adhere to provider policies and procedures. All incidents
will be reviewed and actions implemented as required. All staff working within the service will
have achieved competency in both assessment and procedure management including a clear
understanding of possible complications.
The service is to fully participate in local networks and national networks
3. Service Delivery
3.1 Service model
The service will be provided at accredited Optometrist practices on Wirral. Accreditation will be
by completing the pre cataract element of the electronic distant learning LOC Support Unit
WOPEC training package Cataract Services CD ROM. Where the provider has been providing
the service for some time, accreditation will be required within 6 months of signing this
agreement.
For those newly joining the scheme accreditation will be required prior to the commencement of
the agreement. Such optometrists will be accredited with Slit lamp and Volk Lense plus they will
have completed the pre Cataract Assessment element of the LOC Support Unit WOPEC
training package Cataract Services CD ROM
Those providing the scheme will employ an accredited Optometrist and have the following
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equipment available o Slit lamp and Volk / fundus viewing lens

o Thresholds fields equipment 60 point or more capable of producing a printed report
o Appropriate ophthalmic drugs (Mydriatic, Anaesthetic, Staining agents)
o Standard optometric sight testing equipment
3.2 Competencies
The competencies required for participating optometrists are the standard core competencies as
defined by the GOC and local accreditation as per 3.1.
Participating optometrists within the scheme will have knowledge of the referral criteria and
interpretation of results and the disease process.
3.3 Care Pathway(s)
The following map of medicine pathway is to be followed (detailed at Appendix 2)

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4. Referral, Access and Acceptance Criteria

4.1 Geographic coverage/boundaries
This service is to be provided on a Wirral wide basis and NHS Wirral aims to ensure good
coverage to enable patients to be able to access the service close to home. It will therefore
ensure there is reasonable geographic coverage.
4.2 Location(s) of Service Delivery
The service will be provided within individual accredited optometrist practices on Wirral and will
ensure reasonable geographic coverage.
4.3 Days/Hours of operation
The service will be provided within existing working hours within each individual accredited
optometrist practice on Wirral who wishes to provide the service where the practice is open for a
minimum of 4.5 days per week
4.4 Referral criteria & sources
Referral
o GP
o Self referral
o Non accredited Wirral optometrist
Criteria
o Significant Visual Acuity Loss (as a guide 6/12 or less) or better with significant Visual
Symptoms e.g. glare.
4.5 Referral route
o Own practice patients identified as having suspected cataracts during the standard sight
test.
o Directly from GP.
o Directly from a non participating Optician referred into the service will be identified as having
suspected cataracts during the standard sight test using a GOS 18.
4.6 Exclusion criteria
o Patients not registered with a Wirral GP
o Patients under 16 years
o Patients with dual pathology who should be referred for general ophthalmological
assessment.
4.7 Response time & detail and prioritisation
Own practice patients reviewed for cataract assessment by an authorised optometrist should
have their assessment carried out within 20 working days of the date of initial assessment.
Patients referred from a non participating optometrist will be seen within 20 working days of the
date of referral and patients referred from a GP will be seen within 10 working days of the date
of referral.
5. Discharge Criteria and Planning
Patients who do not require onward referral for surgery will be discharged back into the care of
their registered GP or the referring optometrist.
Patients requiring full assessment and surgery will be referred directly to specialist provider
following the offer of Choice.

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6. Prevention, Self-Care and Patient and Carer Information

In order to involve patients in their care and to help them understand how to manage their
condition, patients and their carers shall be given appropriate information, evidence based
where appropriate, by providers in an accessible format.
7. Baseline Performance Targets Quality, Performance & Productivity
Performance
Indicator

Infection
Control

Service User
Experience

Reducing
Barriers

Improving
Productivity

Indicator

Threshold

The Provider
must ensure
compliance
with the Health
and Social
Care Act 2008:
Code of
Practice for the
Prevention and
Control of
Healthcare
Associated
Infection in all
provider
services
identified in
this SLA. The
following must
take place in
the next 12
months
.

A self-assessment
of all services
against Essential
Steps to Safe
Clean Care.
Where provider
services undertake
clinical
interventions that
fall outside the
scope of the
Essential Steps
framework, the
Saving Lives
programme and
relevant High
Impact
Intervention Care
Bundles (HII) will
be incorporated
into the
assessment
process.

A user survey
is offered to all
patients

Questionnaire and
evaluating process
to be agreed in
advance with the
commissioners.

An action plan (if

required) to be
agreed with the
PCT

Bi annual meeting
- feedback

An action plan (if

required) to be
agreed with the
PCT

Evaluation report
on strategy by
the end of Q4

An action plan (if

required) to be
agreed with the
PCT

Monthly
reporting

The service to
identify
characteristics
that are
barriers to
access
Determine
baseline for
DNAs and
cancellations.

Achieve a
maximum monthly
DNA rate of 5%

Method of
Measurement

An action plan
(if required) to
be agreed with
the PCT from
the
assessment

Frequency
Monitoring

of

Month 9

Report detailing
experience with
recommended
improvements
due end of month
9.

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Achieve a
maximum monthly
cancellation rate of
5%
90%
Conversion
Rate being
achieved

Audit of
outcome of
referrals from
Optometrists

90% of referrals
should result in
surgery

An action plan (if

required) to be
agreed with the
PCT

Bi Annual
Reporting

Access

Adherence to
accessibility
targets

Performance
Indicators

An action plan (if

required) to be
agreed with the
PCT

Monthly
reporting

Method of
measurement

Baseline Target

Threshold

Audit

100%

95 100%

8. Activity
Activity
Performance
Indicators
All patients
attending for
cataract preoperative
referral
assessment
service in 4.4
will receive
cataract
assessment
within the
timescales in 4.7

Frequency
Monitoring

of

Monthly
reporting

9. Currency and Prices

9.1 Currency and Price
For the purposes of these costings the fee payable to Optometrists per patient seen / treated is
35.00 per patient.

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Appendix 2 Map of Medicine Care Pathway

Locally reviewed: Due for review: 31-Aug-2010 Printed on: 08-Apr-2010 Map of Medicine Ltd
IMPORTANT NOTE
Locally reviewed refers to the date of completion of the most recent review process for a pathway. All pathways are reviewed regularly every
twelve months, and on an ad hoc basis if required. Due for review refers to the date after which the pathway on this page is no longer valid
for use. Pathways should be reviewed before the due for review date is reached.

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Cataract LWP
Surgery > Ophthalmology > Cataract

1 Blurred Vision - suspected cataract

Quick info:
Scope:
this pathway covers diagnosis and management of ocular cataracts in adults
Definition:
ocular cataract is defined as a loss of transparency of the ocular lens, which may result in a significant change in
the colour of the lens and the distortion of light transmission through the lens
Cataract may be:
age-related
congenital
idiopathic
secondary to causes such as diabetes, long-term corticosteroid use or trauma Incidence and prevalence:
in the UK, cataracts are present in one or both eyes in about a third of people aged over 65 years
Risk factors:
increasing age
female gender
family history
diabetes mellitus
uveitis
smoking
alcohol use
low socio-economic status
use of systemic or inhaled steroids
eye trauma or surgery
References:
Royal College of Ophthalmologists. Cataract surgery guidelines. London: Royal College of Ophthalmologists;
2004.
American Academy of Ophthalmology (AAO). Cataract in the Adult Eye. San Francisco, CA: AAO; 2001.

2 Typical presentation
Quick info:
people with cataract may present with some or all of the following, especially if cataract is bilateral:
reduced visual acuity inability to distinguish detail from a distance (e.g. bus numbers) or close up (e.g. inability
to read small print)
reduced contrast sensitivity difficulty recognising faces
increased glare
consequences of reduced visual function, such as falls
initial presentation may be to the optician, who may then refer directly to an ophthalmologist.
cataract may also be discovered on routine eye tests carried out by an optician or during routine eye screening
that is part of the follow-up for chronic conditions such as diabetes mellitus

4 Co-morbidities Urgent
Quick info:
Follow urgent co morbidities pathway referral guidelines
Please see here for a copy of the guidelines

5 Clinical assessment
Quick info:
Clinical assessment should ideally be carried out by an optometrist.
If the patient presents with co-morbities they will be automatically excluded from this pathway.
perform dilated ophthalmoscopic examination to assess for cataract and co-morbidity:
fundus may not be clearly visible
opacities in lens
loss of clarity or change in colour of lens
assess for presence of risk factors for cataract:
increasing age
corticosteroid use
diabetes mellitus
history of ocular trauma
high alcohol intake
smoking

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 assess effects on quality of life, function and occupation:

decline in visual acuity may preclude patient from some occupations
what is the patient no longer able to do or enjoy?
document any pre-existing conditions that may affect suitability for surgery
further testing is not routinely needed before referral
The aims of assessment are to:
confirm the presence of cataract (see images of traumatic cataract and radiation cataract)
assess its effects on visual function and quality of life (and to verify that it is a principal cause of any loss of
function)
check for other ocular co morbidities including:
moderate or severe blepharitis (see image of blepharitis) infected skin ulcers or other lesions around the eye
significant entropion or ectropion
assess for systemic disorders that may be contributing to ocular symptoms
assess suitability for surgery
Making the diagnosis:
perform ophthalmoscopic examination
take history of previous near and far vision to assess whether the cataract is likely to be the principal cause of
the patient's
symptoms
assess visual acuity in both eyes, with and without refractive correction
assess other problems with vision (glare, difficulties in contrast sensitivity)
examine the cornea
Assessing severity:
effect on activities of daily living and quality of life
there is no single threshold for surgery this depends on the effect on vision and effect on activities of daily
living
Assess for other disorders that may explain or contribute to decreased visual function:
check for refractive errors
measure intra-ocular pressure and if necessary, the visual fields
examine fundus for signs of retinal disorders (such as age-related macular degeneration)
check for corneal disorders and anterior and posterior chamber disorders
The patient must be provided with a leaflet which includes information about the risks and benefits and the
consent process.
Information about all local providers of cataract surgery should be provided to allow for patient choice.
References:
Royal College of Ophthalmologists. Cataract surgery guidelines. London: Royal College of Ophthalmologists;
2004.
American Academy of Ophthalmology (AAO). Cataract in the Adult Eye. San Francisco, CA: AAO; 2001.

6 Co-morbidities non urgent

Quick info:
Refer via GP for a General Opthalmogical review

7 Referral to ophthalmologist
Quick info:
Referrals should be made using the specified referral form, which where possible, should be completed
electronically and then printed out for signing.
referral can be initiated by either the optometrist or GP, and should be according to local protocols
the following principles should be considered, regardless of method of referral:
sufficient cataract to account for the visual symptoms
the cataract should affect the patients lifestyle
discuss the risks and benefits of surgery with the patient and supply relevant written information
ensure that the patient agrees to cataract surgery
provide this information together with a report from a recent sight test on the referral form
GPs should consider other groups who may benefit form referral for an opinion without meeting the criteria for
direct access to surgery, including:
patients with significant co-morbidity who might benefit from surgery
patients with lifestyle impairment due to cataract who do not complain, particularly those who live alone or act as
carers
patients who require treatment or monitoring of posterior segment disease, e.g. diabetic retinopathy,
anisometropia or lens induced ocular disease
References:
Royal College of Ophthalmologists. Cataract surgery guidelines. London: Royal College of Ophthalmologists;
2004.
American Academy of Ophthalmology (AAO). Cataract in the Adult Eye. San Francisco, CA: AAO; 2001.

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9 Pre Op Assessment
Quick info:
If the decision not to operate is made a letter informing of the reasons why should be sent to the GP and the
referring optometrist.
The aims of assessment are to:
Assess fitness for surgery:
consider any comorbidities that may affect fitness for surgery such as:
hypertension
orthopnoea
hearing difficulties
diabetes
hypertension
consider patient's medical history such as previous corneal refractive surgery (e.g. LASIK or LASEK)
establish if the patient is taking any medications such as warfarin or antiplatelet drugs
assess whether the patient has problems lying flat or co-operating with instructions
consider electrocardiogram (ECG) if history of cardiac disease consider ability of patient to cope at home after
surgery
Consider the following tests, depending on circumstances:
visual field assessment if suspected retinal detachment, tumour, optic nerve disease or glaucoma
Amsler grid if suspected macular disease
corneal measurements if previous corneal surgery
B-scan ultrasound if suspicion of tumour and poor view of fundus due to cataract
colour vision testing if suspected optic nerve problem or macular disease
electrophysiology (visual evoked potentials) if need to assess potential visual function but cataract severe so
cannot test in the usual way
Assess indications or contra-indications for cataract surgery:
check that cataract is the principal cause for patient's visual symptoms
consider other ocular disorders and age-related macular degeneration if present, cataract surgery may be less
effective
patient's desire for surgery after discussion of risks and benefits
consider current medication
allergies
Factors influencing surgical technique:
previous laser or surgical treatments to the eye (e.g. LASIK or LASEK)
biometry (measurement of the axial length of the eye and corneal curvature) is required to calculate the correct
implant power and size:
this may be performed by a suitably trained ophthalmologist, ophthalmic technician, nurse or optometrist
needs to be performed far enough in advance of surgery to order the correct lens and discuss with the patient
the level of vision that is likely to be achieved
measurements are often inaccurate in patients who have had previous refractive surgery
Following the pre-op assessment the patient will be given a date when the surgery is due to take place. The
patient will also be made aware of the follow up procedures.
References:
Royal College of Ophthalmologists. Cataract surgery guidelines. London: Royal College of Ophthalmologists;
2004.
American Academy of Ophthalmology (AAO). Cataract in the Adult Eye. San Francisco, CA: AAO; 2001.
American Optometric Association (AOA). Care of the adult patient with cataract. St Louis, MO: AOA; 2004.

10 Surgery
Quick info:
Peri-operative care:
ensure that systemic comorbidities (e.g. diabetes mellitus, cardiac failure and hypertension) are well controlled
before surgery
ensure that glaucoma is well controlled before surgery
consider prophylactic oral and/or topical antibiotics before, during and after surgery if risk of serious infective co
morbidity
prophylactic topical non-steroidal anti-inflammatory drugs are commonly used before, during and after surgery
with the aim of
reducing the risk of macular oedema, although one systematic review suggested that its effectiveness is uncertain
povidone-iodine antiseptic to clean site to prevent infection
counsel patient on risks of surgery
Surgery:
usually day case
often performed topically with local anaesthetic

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 consider general anaesthetic if, for instance, severe tremor, confusion, inability to comply with instructions,
marked anxiety
may need overnight stay if general anaesthetic or no carer available for patient
even if bilateral cataract is present, only one eye is operated on at a time, to reduce the risk of bilateral loss of
vision should complications occur
the usual operation is phacoemulsification and intra-ocular lens implant in the UK:
pupil is dilated with drops
eye is always anaesthetised
incision is made in the eye
lens is destroyed with sound waves
lens material is removed
plastic lens is inserted instead
eye incision usually self-seals but may be closed with a stitch if necessary
operation is sometimes combined with glaucoma surgery (trabeculectomy) if present; however sequential
procedures are preferred to optimise long-term success
sharp edged intraocular lenses (IOL) produce less posterior capsule opacification than round edged equivalents
overall, around 80-90% of patients report a benefit from surgery
Advanced cataract surgery:
capsular tension rings
iris hooks
prosthetic iris devices
Intraoperative floppy iris syndrome:
associated with Flomax (tamsulonin) usually prescribed for elderly with prostate problems
References:
Royal College of Ophthalmologists. Cataract surgery guidelines. London: Royal College of Ophthalmologists;
2004.
American Academy of Ophthalmology (AAO). Cataract in the Adult Eye. San Francisco, CA: AAO; 2001.
American Optometric Association (AOA). Care of the adult patient with cataract. St Louis, MO: AOA; 2004.
Sivaprasad S, Bunce C, Patel N. Non-steroidal anti-inflammatory agents for treating cystoid macular oedema
following cataract surgery. Cochrane Database Syst Rev 2005; CD004239.
Ciulla TA, Starr MB, Masket S. Bacterial endophthalmitis prophylaxis for cataract surgery: an evidence-based
update.
Ophthalmology 2002; 109: 13-24.
Findl O, Buehl W, Bauer P et al. Interventions for preventing posterior capsule opacification. Cochrane Database
Syst Rev. 2007 Jul
18;(3): CD003738.

11 Follow up
Quick info:
Review at 1-4 weeks:
check visual acuity, intra-ocular pressure
auto-refraction to screen for refractive surprise
eye examination
discussion of post operative results
management of post operative refractive error
collection of outcome data
listing of second eye
References:
Royal College of Ophthalmologists. Cataract surgery guidelines. London: Royal College of Ophthalmologists;
2004.

12 Optometrist Follow up
Quick info:
new spectacles can be prescribed 4 weeks after small incision surgery, and up to 12 weeks after extracapsular
surgery, as the refraction of the new lens will usually differ from the original lens
References:
Royal College of Ophthalmologists. Cataract surgery guidelines. London: Royal College of Ophthalmologists;
2004.
American Academy of Ophthalmology (AAO). Cataract in the Adult Eye. San Francisco, CA: AAO; 2001.

13 Be alert for complications

Quick info:
Symptoms of complications include:
reduced vision
increased pain

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 discharge from eye

swelling around eye
Early (within 48 hours of surgery) complications:
infected endophthalmitis
postoperative intra-ocular pressure rise (may need ocular hypotensive treatment for up to a month)
Late complications:
macular oedema (may need topical NSAID)
retinal detachment
posterior capsule opacification:
after surgery, residual cells from the original lens hinder light passing through new lens
can cause reduced vision, blurred vision or glare
usually occurs within 2 years of surgery, but can be many years later
particularly a problem in children
advise patient to come back if vision deteriorates again
usually treated with laser therapy or occasionally surgical lens removal
References:
Royal College of Ophthalmologists. Cataract surgery guidelines. London: Royal College of Ophthalmologists;
2004.
American Academy of Ophthalmology (AAO). Cataract in the Adult Eye. San Francisco, CA: AAO; 2001.
American Optometric Association (AOA). Care of the adult patient with cataract. St Louis, MO: AOA; 2004.

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Appendix 3 Referral Proforma

Cataract Referral Assessment

Surname

Previous Surname

Forename

Date of Birth

Address

Telephone No
Post Code

Date of previous Eye Test

GP Details

Refraction
Sph
RE
LE
Corneal Examination
RE
LE
Tonometry
RE
LE

Cyl

Axis

Prism

V/A

Description of Cataracts
RE
LE
Visual Fields
RE
LE

Add

N V/A

Fundus Appearance
RE
LE

Comments

Pneumo /
Applanation
Details of Ocular History

Relevant Medical History & Medication

Warfarin Yes / No

Apririn Yes / No

Tamsulosin (Floxmax) Yes / No

Reason for referral

Details of GP

Name

Details Referring Practitioner

______________________________

Details of assessing
practitioner

Date __________________

Signature ______________________________

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