1. TRAINING FOR ANTICOAGULATION IN PRIMARY CARE AND THE NEW GP CONTRACTS (Enhanced Services)

2. National Enhanced Service GMS contract document definition An Anticoagulation monitoring service is designed to be one in which 1.Therapy should normally be initiated in secondary care, for recognised indications for specified lengths of time 2. Maintenance of patients should be properly controlled 3. Service to the patient is convenient 4. The need for continuation of therapy is reviewed regularly 5. The therapy is discontinued when appropriate

3. FUNDING National Enhanced Service outline Available upon the completion of the following 1.Development and maintenance of a register 2.Call and recall 3.Professional links 4.Referral policies 5.Education and newly diagnosed patients 6.Individual management plan 7.Clinical procedures 8.Record keeping 9.Audit 10.Training - each practice must ensure that all staff involved in any aspect of care under this scheme have the necessary training and skills to do so

4. DOSING From National Enhanced Service Document A “Doser” means any person who is suitably trained and qualified, who upon receipt of relevant information from laboratories or near-patient testing equipment or otherwise, with or without computer assisted decision making equipment, determines as the relevant service may require, the anti- coagulant dosage for patients of practitioners in a practice. In other words…. Trained staff to dose patients

5. WHAT IS REQUIRED OF A PROVIDER OF ANTICOAGULATION MONITORING? Meticulous preparation before setting up the service SOPs/Protocols-kept up to date Trained staff at appropriate level - continuing and verifiable Audit trail for everything used QA – internal and external Approved equipment

6. Rationale for staffing Cost driven Service driven Optimum use of resources Relief!

7. Two (of many) Responses Secondary care – Relief “Let’s get shot of it in our overworked, understaffed laboratories” Primary Care – Keep costs to a minimum “Let’s use HCA’S, a monkey could do it” Lack of understanding of potential disaster with inappropriate staffing and training

8. Staff currently monitoring Anticoagulation in Primary Care Biomedical Scientists Specialist nurses Practice nurses Pharmacists Doctors Health Care Assistants!!

9. STAFFING FOR AC MONITORING Duty of care to patients: the level of responsibility should be reflected in staff suitability Skills should be suited to the task

10. STAFF AVAILABILITY Biomedical Scientists - Chronic shortage Suitably skilled Practice Nurses Abundance of Health Care Assistants available to free skilled nurses

11. Trained staff at appropriate level - continuing and verifiable In the interests of best practice, clinical governance and professional accountability, it is important the clinics are set up and managed appropriately. Prior to the commencement of an anticoagulation clinic staff with responsibility for running them should undergo thorough competence training.

12. PERSONNEL TRAINING Requirements prior to training Content of programme Who will deliver training Where training will be delivered Verifiable – assessment/certification

13. Basic training should include Understanding the basic principles of measurement Understanding of the mode of action and side effects of warfarin How to deal with these Understanding how to monitor and maintain therapy Knowledge of risk factors Basic knowledge of common drugs that interact with warfarin Understanding of dosing, using approved protocols Competent use of computer dosing systems where used Knowledge of bleeding events and thrombotic events and when to refer How to set-up and manage a clinic Knowledge of quality assessment and necessity for using controls Understanding of the importance of patient education and involvement Understanding the use of all testing equipment and record keeping Knowledge of safety procedures Understanding of their accountability in the management of warfarin therapy Continuous Professional Development THE WHOLE LOT !

14. CURRENT TRAINING OPTIONS Formal courses at Training Centres In - House locally developed training schemes Secondary Care developed training schemes Provision of equipment and instruction manuals –“the Get on with it” approach

15. Biomedical Scientists Haematologists Nurses Pharmacists Doctors And enlightened PCT managers! Excellent formal training centres as a result of collaboration between

16. Established organisations throughout the UK Birmingham University Contact Prof David Fitzmaurice or Ellen Murray Barnet and Chase Hospital Contact Bunis Packham University of Hertfordshire Contact Carol Law Somerset Coast PCT Contact Nicola Fleming or Helen Hartley CLOT-North Hants Hospital Contact Vicki Warburton

17. INSTITUTE OF BIOMEDICAL SCIENTISTS WHAT NEXT? ADVANCED SPECIALIST CERTIFICATES IN POINT OF CARE TESTING ?

18. ADVANCED SPECIALIST CERTIFICATES (Quote from IBMS gazette July 2003) Additional certificates will be developed in response to service The content and therefore professional level of these advanced specialist certificates will vary These will enhance professional practice and allow Biomedical Scientists to demonstrate expertise in specific areas

19. TRAINING FOR ANTICOAGULATION IN PRIMARY CARE AND THE NEW GP CONTRACTS (Enhanced Services)