Service Restriction Policies
Folder Service Restriction Policies
Mid Essex CCG’s policy is that treatments/ interventions/ procedures not currently included in commissioned established care pathways (as identified for example in the Schedules to the service agreements with acute care provides) or identified for funding through the commissioning process are not routinely funded. For a number of commissioned interventions Mid Essex CCG has specific policy statements setting out restrictions on access, based on evidence of effectiveness or relative priority for funding. Those related to treatments/ interventions/ procedures are included within this document; those relating to prescribing can be found on the Mid Essex CCG website - Medicines Optimisation. Providers must not assume that because a treatment/intervention/procedure is not included in this policy or listed on the Medicines Optimisation website that by default it will be funded.
Policy development is an on-going process and future policy on further treatments as developed or in response to NICE Guidance/Guidelines, health technology assessments etc. will be produced and published periodically on Mid Essex CCG website - Service Restriction Policies.
Each new referral, regardless of advice provided following a previous referral or episode of care, must be assessed against the policy in place on the date the referral is made. The fact that a patient has previously been treated for the referral condition, or a related condition, and previously met the policy in place at the time does not support a referral or treatment outside the current service restriction policy.
This policy document sets out the access to treatments/ interventions/ procedures* where there is a specific policy in place:
Threshold Approvals – Those procedures* which are commissioned by Mid Essex CCG on a routine basis but only for patients who meet the defined criteria set out within this policy but for which individual prior approval is not required e.g. cataract surgery. Mid Essex CCG notification of compliance or audit will be required according to contractual arrangements. Providers should be aware that payment may be withheld where it cannot demonstrate that patients treated meet the criteria specified.
Individual Prior Approvals - Those procedures* which are commissioned by Mid Essex CCG but only for patients who meet the defined criteria set out within this policy and which require individual approval on a patient by patient basis.
For these procedures, the criteria listed form guidance to both the referring and treating clinicians and if a patient is deemed to meet these criteria prior approval should be sought. In instances in which eligibility is unclear the final decision is made through the application of the Exceptional Cases process.
Not Funded – Those procedures* which have been assessed as Low Clinical Priority by Mid Essex CCG and which will not be funded unless there are exceptional clinical circumstances. Applications for funding for these procedures can be made to the Exceptional Case Team but should only be made where the patient demonstrates true clinical exceptionality.
Individual Funding Requests – Mid Essex CCG always allows patients the opportunity to make specific funding requests via its Exceptional Case Team. Requests may include patients with conditions for which Mid Essex CCG does not have an agreed policy, including patients with rare conditions and patients whose proposed treatment is outside agreed service agreements. Such requests should not constitute a request for a service development.
Equality and Diversity - The Equality Act 2010 protects people against unfair treatment (discrimination) on the grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. The Equality Act defines ‘disability’ as a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day to day activities.
Providers are reminded that under this Act they must make adequate and reasonable adjustment to services, which includes provision for interpreters, carers and for others from whom patients may require assistance, providing information and/or signage in an appropriate range of formats, media and languages. Providers shall ensure that service and customer care is delivered in an inclusive manner which respects the diversity of users. It is therefore unlikely that an application for additional funding for such adjustments will be successful.
Children and Families Act 2014 - All providers are also reminded that they must take into account the requirements of the Children and Families Act 2014. Service provision must be delivered to young people 19-25 years of age if they have an Education Health and Care Plan in place.
The responsibility for adherence to these policies lies with the treating clinician and failure to adhere to these criteria may result in non-payment of the activity.
All patients being referred for non-urgent elective surgery who are smokers should be referred to smoking cessation services by the GP at the time of referral, and should be non-smokers at the time of surgery. There is strong evidence of higher risks and worse surgical outcomes when a patient continues to smoke. The risks associated with smoking mean that it is not always safe for surgery to take place when a patient continues to smoke and, as a result, some surgeons will not carry out procedures until a patient is able to abstain from smoking. For smokers who are unable to quit, the Royal College of Anaesthetists advises that smokers should give up smoking for at least several weeks before surgery and certainly not to smoke on the day of an operation. Smokers are 38% more likely to die after surgery than non-smokers.
There is strong clinical evidence that obese patients undergoing surgery are at significantly higher risk of getting infections and suffering heart, kidney and lung problems than people who are a healthy weight. They are also likely to have to spend more time in hospital recovering and their risk of dying as a result of surgery is higher compared to patients with a normal weight.Overweight patients are strongly encouraged to lose weight BEFORE their operation and should consider delaying referral for non-urgent elective surgery; this is particularly applicable to patients who have a BMI over 40 or those with a BMI between 30 and 40 who have metabolic syndrome - a combination of diabetes, high blood pressure and obesity. Patients should aim to reduce their weight by at least 10% over 9 months or to a BMI of less than 30.
*includes treatments, interventions and procedures
pdf Prior Approval Application Form (212 KB) - If you are seeking funding for a treatment which is covered by the current Service Restriction Policy and you believe that the patient meets all relevant critera.
pdf Exceptional Clinical Circumstances Application Form (208 KB) - If you are seeking funding for a treatment which is covered by the current Service Restriction Policy but the patient does not meet the current criteria and you wish to apply for exceptional funding.
pdf Individual Funding Request Form (227 KB) - If you are seeking funding for a treatment/technology for a medical condtion where the CCG has no established commissioning policy.
Update: 20th August 2018
As from Monday 20th August 2018, the new Mid & South Essex STP Value Based Commissioning Policies comes into effect.