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Folder Value Based Commissioning Policies

The over-riding commissioning policy requirement is that all commissioning must be based on value for money, defined as "the best mix of quality and effectiveness for the least outlay".

Mid & South Essex CCGs' commissioning position is that treatments/ interventions/devices/ procedures* (hereafter known as 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 procedures M&SECCGs operate a Prior Approvals Scheme setting out criteria for access, based on evidence of effectiveness or relative priority for funding. Those related to procedures* are included within this document; those relating to prescribing can be found on the commissioner Medicines Optimisation website.. Providers must not assume that because a procedure* is not included in this document or listed on the Medicines Optimisation website that by default it will be funded.

Commissioning policy development is an on-going process and future commissioning policy on future procedures* as developed or in response to NICE Guidance/Guidelines, health technology assessments etc. will be produced and published periodically on M&SECCGs' websites - document Commissioning Policies (1.95 MB)  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 procedures* where compliance with the Prior Approvals process is required.

For these procedures* the criteria listed apply to both the referring and treating clinicians GPs should not refer patients who do not meet criteria which they can access. This not only takes up unnecessary outpatient appointment but results in a poor patient experience.

Equally treating clinicians should review and return to the GP those where it is clear from the information provided that the patient does not meet criteria, thus reducing the number of inappropriate outpatient appointments. Providers are contractually obliged to abide with the Prior Approvals scheme and failure to do so is a breach of that contractual obligation and any unapproved activity will not be funded.

The following sets out the different levels of Prior Approval recognised by M&SECCGs.

Group Prior Approvals (previously known as Threshold Approval  – Those procedures* which are commissioned by M&SECCGs on a restricted basis only for patients who meet the defined criteria set out within the relevant commissioning policy but for which individual prior approval is not required e.g. cataract surgery. M&SECCGs notification of compliance or audit will be required according to contractual arrangements. Providers should be aware that payment may be withheld where they cannot demonstrate that patients treated meet the criteria specified.

The Group prior approval should be applied in line with the policy in force at the time the patient is listed (where relevant) for the procedure*. This approval will last for 12 months. After 12 months have elapsed the patient should be reviewed against the policy in force at the time and the criteria for the procedure* will apply. Subsequent reviews should be undertaken in line with the policy in force at the time and approval time limits will also be in line with the policy in force at the time.

This process and associated time limits will apply unless an alternative policy is subsequently introduced for a named procedure*.


Individual Prior Approvals - Those procedures* which are commissioned by M&SECCGs but only for patients who meet the defined criteria set out within the relevant commissioning policy and which require individual approval on a patient by patient and, in some circumstances, treatment by treatment basis e.g. botox before the treatment can be provided.

For these procedures*, the criteria listed apply to both the referring and treating clinicians and if a patient is deemed to meet these criteria individual prior approval must be sought. When applicable, GPs should seek indivudual prior funding approval before a referral is made/outpatient appointment is booked. 

Individual prior approval should be sought in line with the policy in force at the time the patient is identified as requiring the procedure* (where relevant) for the proceudre*. Once approved the individual prior approval will be valid for 12 months. After 12 months have elapsed the patient should be reviewed against the policy in force at the time and the criteria for the procedure* will apply, if the procedure* continues to be required, a new individual prior approval application should be made, Subsequent reviews should be undertaken in line with the policy in force at the time and approval time limits will also be in line with the policy in force at the time.

This process and associated time limits will apply unless an alternative policy is subsequently introduced  for a named procedure*.

Not Funded – Those procedures* which have been assessed as Low Clinical Priority by M&SECCGs and which will not be funded unless there are exceptional clinical circumstances. Applications for funding for these procedures* can be made using the Individual Funding Request process but should only be made where the patient demonstrates clinical exceptionality.

 

Legacy patients

It is acknowledged where funding criteria has changed there will be patients who have received funding for a procedure* under a previous policy which is no longer funded or the criteria for funding has changed. Where for clinical reasons a previously funded procedure* needs repeating/revision/replacement the current policy applies.

Individual Funding Requests (IFR) – M&SECCGs always allows clinicians on behalf of their pateints the opportunity to make specific funding requests via the IFR process. Requests may include patients with conditions for which M&SECCGs do not have an agreed commissioning policy, including patietns with rare conditions, and patients whose proposed treatment is outside agreed commissioning policies (exceptional clinical circumstances) or 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. Commissioned service provision for children 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.

Smoking and Surgery

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 strongly encouraged to 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.

Obesity and Surgery

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.

 

 

document (1.95 MB) document Mid & South Essex STP (1.95 MB)

document Exceptional Clinical Circumstances Form - Drugs Only (178 KB)

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.

pdf Individual Funding Requests and Exceptional Cases Policy (701 KB)

pdf Patient Information (299 KB)

Update: 20th August 2018

As from Monday 20th August 2018, the new Mid & South Essex STP Value Based Commissioning Policies comes into effect. 

 

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