Author: dobe1
Last saved by: D O
Company: NHS Connecting for Health

Annex A
Recommendation for PCT to be specified in the Electronic Prescription Service Authorisation Directions

SHA Details
SHA | Enter SHA name.
SHA Contact Details | Enter SHA contact details.  Please include name, email and telephone.
PCT | Enter PCT name that request is for (separate form required for each PCT).

SHA Criteria (please add more rows as required) | | PCT Met? (Y/N)
Enter SHA Criteria (add more rows if appropriate) |

Declaration by SHA CIO

Enter SHA name Strategic Health Authority requests that Enter PCT name PCT is included in the list of PCTs that may authorise the use of the ETP service, in accordance with the provisions of the Primary Medical Services (Electronic Prescription Service Authorisation) Directions 2008 as amended, with effect from enter date.
Enter PCT name PCT has met the criteria set by Enter SHA name Strategic Health Authority.
Print Name: | Enter name | Signed: |
Date: | Enter date | |

Please submit request to eps.authorisation@dh.gsi.gov.uk. A hard copy of the signed form also needs to be sent to Beth Foster, Department of Health, Room 456D, Skipton House, 80 London Road, London SE1 6LH.

PCT Summary
             
PCT Name | Enter name of PCT for which Secretary of State Direction is required.  Please note this should be the legal name of the PCT as stated in the appropriate Statutory Instrument.
PCT Contact Details | Enter PCT contact details.  Please include name, e-mail and telephone.
| Total Number | % TGL Release 1 | % BGL Release 1
GP Sites | Enter no | Enter % | Enter %
Dispensing Doctors | Enter no | Enter % | Enter %
Pharmacy Sites | Enter no | Enter % | Enter %
DAC Sites | Enter no | Enter % | Enter %

System Supplier Coverage

InPS: 
Vision 3

EMIS: 
LV

EMIS: PCS

EMIS WEB

iSoft: Premier or Synergy

Microtest: 
EPS Module

Healthy: Crosscare

CSC/TPP: SystmOne

Prescribing Systems | Enter % | Enter % | Enter % | Enter % | Enter % | Enter % | Enter % | Enter %

Lloyds: 
Compass

AAH: Proscript Link

Positive Solutions: Analyst

RX:
Proscript

Swebtec: Pharmasys

Cegedim: 
Pharmacy Manager

Cegedim: Nexphase

Helix: 
QicScript

Dispensing Systems | Enter % | Enter % | Enter % | Enter % | Enter % | Enter % | Enter % | Enter %

Programme Governance

Date Programme Board established | dd.mm.yy | Name of EPS Lead: | Enter name
Date of last LPC presentation | dd.mm.yy | |
Date of last LMC presentation | dd.mm.yy | |

Proposed Initial Pairings (Up to 5 sites to be listed)

Prescribing Site Name | | Dispensing Site Name |
Prescribing Site NACs Code | | Dispensing Site NACs Code |
Prescribing Site System | | Dispensing Site System |
Prescribing Site Name | | Dispensing Site Name |
Prescribing Site NACs Code | | Dispensing Site NACs Code |
Prescribing Site System | | Dispensing Site System |
Prescribing Site Name | | Dispensing Site Name |
Prescribing Site NACs Code | | Dispensing Site NACs Code |
Prescribing Site System | | Dispensing Site System |
Prescribing Site Name | | Dispensing Site Name |
Prescribing Site NACs Code | | Dispensing Site NACs Code |
Prescribing Site System | | Dispensing Site System |
Prescribing Site Name | | Dispensing Site Name |
Prescribing Site NACs Code | | Dispensing Site NACs Code |
Prescribing Site System | | Dispensing Site System |
PCT Operational Readiness

Product Name

Current Status
Not Started, In Development or Signed Off

Planned sign off date

Project management and governance | |
PCT Deployment plan | |
Communications and stakeholder engagement strategy | |
Nomination policy | |
Smartcard transition plan | |
Business continuity guidance (for prescribers and dispensers) | |
Business process mapped & communicated to stakeholders | |
Training strategy | |
Patient enablement strategy | |
Dispensing tokens (FP10 DT) distribution plan | |

Any additional comments in relation to the data inputted on pages 2-3.  

Please use this freetext box if you have any points to make in relation to the data inputted above, where you think the panel may find anything anomalous (for example if certain dates entered in the Programme Governance section are not very recent),  or you feel supporting information would be beneficial. [Maximum of 200 words]

PCT’s Case for Inclusion 

Please use this freetext box to state this PCT’s case for inclusion in the Secretary of State Directions at this point in time. This should have a local emphasis on the PCT. The SHA may also wish to add further comments based on their own process of assessing the PCT. [Maximum of 300 words]

Third version of form 	July 2012		Page  of