berkshire west federated ccgs restricted procedures ... is to be completed. ... arthroscopic lavage...

NHS STANDARD CONTRACT 2017/18 and 2018/19 PARTICULARS (Full Length)

RHW ROYAL BERKSHIRE NHS FOUNDATION TRUST

© SCW CSU - Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2016/17 V5 19.12.16

Newbury and District Clinical Commissioning Group North and West Reading Clinical Commissioning Group

South Reading Clinical Commissioning Group Wokingham Clinical Commissioning Group

Version 5

Status FINAL

Author Sarah Robson, Head of IFR

Date Created Original 1st April 2015

Date Last Update 1st December 2016

Berkshire West Federated CCGs Restricted Procedures,Treatments and Interventions 2017/18



© SCW CSU - Berkshire West CCGs - Restricted Procedures,Treatments and Interventions 2017/18 V5 19.12.16 1

Introduction This document sets out those services, procedures, treatments and interventions where Berkshire West Federated CCGs (BWCCGs) require Providers to work with them to ensure patients are treated in line with commissioning policies, approval process and decisions. It outlines treatments not routinely commissioned or restricted to clinical criteria. The function for addressing individual funding requests lies with Central Southern Commissioning Support Unit (CSCSU) through its IFR service which acts on behalf of BWCCGs. This work is driven by the need to ensure that NHS funded treatments are effective and evidence-based. It also attempts to define more clearly and openly the limits of NHS funding for procedures with social but not physical benefits e.g. cosmetic procedures. Although not the main driving force, it is also linked to the need to ensure that the NHS provides value for money and achieves financial balance. The current proposals can be broadly classified into three categories:

RED: Excluded – procedures not routinely funded by Berkshire West CCGs (formerly known as, including and not limited to, Low Priority, PLCV and Never Dos)

AMBER: Procedures that require prior approval by written communication through the IFR team who manage these requests on behalf of Berkshire West CCGs (formerly known as threshold dependent procedures (TDP)

GREEN: Funded Subject to Audit – procedures that are routinely funded subject to criteria and will be subject to audit of an agreed sample of activity.

Red - Procedures not routinely funded (excluded) These are procedures that will not be routinely funded by the CCGs due to a lack in clinical benefit, limited resource or the responsibility of specialised commissioning. Individual funding requests (IFR) may be made to the patient’s CCG for consideration, where exceptional circumstances exist via the IFR team through the IFR process, as outlined on the following website: http://www.fundingrequests.cscsu.nhs.uk/berkshire-west/ Amber - Procedures that require prior approval For these procedures it is known that the benefit from the intervention is expected to be more effective when the patient meets the criteria, as outlined on the following website. Prior approval is required for all procedures, treatments and interventions in this category. Where available a proforma/checklist is to be completed. http://www.fundingrequests.cscsu.nhs.uk/berkshire-west/ Green - Funded and Subject to Audit For these procedures prior to referral and/or treatment the patient must meet the criteria as outlined on the following website http://www.fundingrequests.cscsu.nhs.uk/berkshire-west/ These cases will be audited and monitored for compliance against the criteria. These procedures will only be commissioned from Providers who will work with us to ensure that patients are only offered treatment where the funding criteria are met. Where patients do not meet the criteria, individual funding requests (IFR) may be made to the patient’s CCG for consideration, where exceptional circumstances exist. For all categories - procedures carried out that do not follow the above outlined processes will not be paid for. Retrospective funding requests are also not accepted and will not be funded. A list of procedures, treatments and interventions can be found in table 1.

http://www.fundingrequests.cscsu.nhs.uk/berkshire-west/






Table 1

Procedure / Treatment Excluded Prior

Approval

Funded Subject to

Audit

Funding requests required from

All specialties

Biological Mesh ● Consultant

Multiple Chemical Sensitivity (MCS) and Clinical Ecology/ Environmental Medicine

● Consultant

MRI scans (Open & Upright) ●

MSK Intermediate Services/Consultant

Neuro-rehabilitation (ABI and Stroke – 2b placements) ● Consultant

Speech and Language Therapy in Parkinson's Disease ● Consultant

Bariatric Surgery

Gastric banding ● Consultant

Gastric bubble (also known as gastric balloon) ● Consultant

Gastric bypass ● Consultant

Severe and Complex Obesity – Tier 1, Tier 2, and Tier 3 ● GP

Stomach stapling ● Consultant

Excess skin removal post weight-loss ● Consultant

Complementary Medicine / Alternative Therapies

Acupuncture ● GP

Acupuncture of the treatment of chronic, non-specific low back pain

● GP

Body Massage ● GP

Functional Therapy Session ● GP

Homeopathy - Complementary therapy ● GP

Hypnosis ● GP

Movement Therapy ● GP

Osteopathy and Chiropractic ● GP

Relaxation Therapy Session ● GP

Dermatology

Botox for the treatment of Hyperhidrosis ● Consultant

Correction of hair loss (Alopecia) including Intralace ● GP

Correction of male pattern baldness ● GP

Eflornithine for facial hirsutism ● GP

Electrolysis for hair removal ●

Hair Transplantation / hair grafting/ Intralace ● GP

Laser removal of skin lesions (haemangioma, portwine stain, HHT, congenital naevi) and excessive hirsutism

● GP

Minor skin procedures (not including BCC and SCC) ● GP

Removal of lipomata ● GP

Removal of Tattoos ● GP

Scar Revision (keloid and hypertrophic scars) ● GP

Sebaceous cysts (pilar and epidermoid cysts) ● GP

Seborrhoeic keratoses (benign skin growths, verrucae, warts), acne vulgaris, rosacea

● GP

Skin resurfacing (dermabrasion, laser and chemical peels) ● GP

Spider naevia ● GP

Telangiectasia ● GP

Xanthelasmas ● GP

Gastroenterology

Anal Irrigation systems for the Management of Faecal incontinence/constipation

● GP/Consultant





Approval

Funded Subject to

Audit

Funding application

required from Gastroenterology (continued)

Botox for Chronic Anal Fissure ● Consultant

Laparoscopic fundoplication for chronic reflux oesophagitis (funding for use in any other circumstance is Low Priority)

● Consultant

Sacral Nerve Stimulation for constipation ● GP/Consultant

Surgical techniques for the treatment of Oesophageal Stricture ● Consultant

The use of laparoscopic gastro-oesophageal reflux surgery (LGORS)

● Consultant

General Surgery

Gallstones (treatment of patients with previously symptomatic gallstones who are now free of symptoms)

● Consultant if

outside of criteria

Hernia (Inguinal and Umbilical) ● GP

Mental Health

ADHD Treatment Pathway for Adults with Attention Deficit Hyperactivity Disorder

● GP

Chronic Fatigue Syndrome / Myalgic Encephalomyelitis inpatient stay

● GP if outside normal

CFS/ME service

Non pharmacological services for dementia patients ● GP

Neurology

Botox for long term Bell’s Palsy ● Consultant

Botox for Sialorrhoea (severe drooling) ● Consultant

Botox for chronic headaches (excluding migraines) ● Consultant

Electrical stimulation (including Functional Electrical Stimulation) for Upper and Lower Limb Dysfunction

● Consultant

Functional Electrical Stimulation in Drop Foot of Central Origin ● Consultant

Obstetrics & Gynaecology

Cryopreservation (male and female) ● NHS Fertility Service

Dilation and curettage in women

● Consultant

Female Sterilisation ● Intermediate Gynae Service/Consultant

Female Sterilisation reversal ● Intermediate Gynae Service/Consultant

Hysterectomy for heavy menstrual bleeding and/ or dysmenorrhoea – indications for surgery (excluding cancer)

● Consultant

In vitro fertilisation (including the prescriptions of infertility drugs) and ICSI (intracytoplasmic sperm injection)

●

NHS Fertility Service/GP where couples who are

outside of criteria

Uterine Artery Embolisation of Fibroids ● Intermediate Gynae Service/Consultant

Ophthalmology

Cataract removal in adults ● Ophthalmologists if

outside of policy

Chalazia (meibomian cysts) ● Ophthalmologists/

GP

Second eye cataract surgery ● Ophthalmologists if

outside of policy

Short sight/long sight corrective (laser) surgery (Refractive keratoplasty)

● Ophthalmologist

Other

Excess Treatment Costs (ETCs) for non-commercial clinical trials

● Consultant





Approval

Funded Subject to

Audit

Funding application

required from Otorhinolaryngology

Adenoidectomy ● Consultant if outside

of policy

Grommets /Myringotomy (children) ● Consultant if outside

of policy

Surgery in the management of chronic rhino sinusitis and nasal polyposis

● Consultant if outside

of policy

Tonsillectomy

● Consultant if outside

of policy

Plastic & Reconstructive Surgery

Abdominoplasty, apronectomy, (tummy tucks) ● GP

Aesthetic/cosmetic genital surgery – male or female ● GP

Appliances & devices for cosmetic purposes (high-grade silicon cosmesis and/or prosthesis)

● GP

Blepharoplasty - (upper and lower eye lid surgery) ● GP

Body contouring procedures (buttock, thigh, calf implants, arm lifts)

● GP

Botox for cosmetic reasons ● GP

Brachioplasty (arm lift) ● GP

Breast asymmetry ● GP

Breast augmentation ● GP

Breast mastopexy ● GP

Breast prosthesis removal or replacement ● GP

Breast reduction ● GP

Clitoroplasty ● GP

Correction of Ptosis ● GP

Corrective surgery to nipple ● GP

Excision of skin tag of anus (not including fistula’s) ● GP

Excision of sweat bearing glands ● GP

Facelift (Rhytidectomy/ Surgical removal of wrinkles)/ Brow lift and Submental lipectomy

● GP

Hymenopathy ● GP

Labiaplasty ● GP

Laser Treatment ● GP

Liposuction ● GP

Male breast reduction for gynaecomastia ● GP

Mammoplasty ● GP

Pinnaplasty (bat ears – adult and children) ● GP

Plastic operations on the Umbilicus ● GP

Reconstruction/Revision of breast (not including post breast cancer)

● GP

Reconstruction/Revision of nose ● GP

Reconstruction/Revision of external ear ● GP

Reconstruction/Revision of body (excess skin removal for all areas)

● GP

Reconstruction/Revision of body (excess skin removal for all areas) post bariatric surgery/weight loss

● GP

Repair of traumatic/ chronic clefts due to avulsion of body piercing

● GP

Removal of supernumerary nipples ● GP

Revision of Breast Augmentation ● GP

Rhinophyma and correction surgery ● GP

Rhinoplasty (cosmetic nose surgery) does not include Septorhinoplasty where there is nasal obstruction

● GP





Approval

Funded Subject to

Audit

Funding application

required from Plastic & Reconstructive Surgery (continued)

Split earlobes, meatoplasty/ plastic operations on external ear (e.g. lobe repair)

● GP

Vaginoplasty ●

GP

Thoracic Surgery

Endoscopic Thoracic Sympathectomy for Facial Blushing and/or sweating

● Consultant

Pectus Anomaly Surgery (including Pectus Excavatum / Pectus Carinatum)

● GP

Trauma, Orthopaedics & Anaesthetics

Arthroscopic Lavage & Debridement for Patients with Osteoarthritis of the knee

● GP

Botulinum toxin Type A for chronic headaches (excluding migraines)

● Consultant

Carpal Tunnel Syndrome ● GP

Corticosteroid injections for elbow tendinopathy (tennis elbow)

● GP/ Consultant

Corticosteroid injections for patellar tendinopathy (jumper’s knee)

● GP/ Consultant

Dupuytren’s Contracture (Palmar Fasciectomy) ● GP

Femoro-acetabular (Hip) Impingement (Arthroscopic and open Approaches) – Surgical Treatment - Hip Impingement surgery

● GP

Facet Joint Injections (FJI) and Medial Branch Blocks for Chronic Low Back Pain – Diagnostic

● GP/ Consultant

Facet Joint Injections (FJI) and Medial Branch Blocks for Chronic Low Back Pain –Therapeutic

● GP/ Consultant

Ganglion Surgery ● GP

Hip and Knee Replacement Surgery - follow up appointments ● GP

Primary hip and primary knee replacement surgery ● GP/ Consultant

Hip Prostheses ● GP

Hip Resurfacing for Advanced Arthropathy ● GP

Low-intensity pulsed ultrasound (marketed in the UK as the Exogen system) for delayed non-union fracture and Teriparatide

● Consultant

Ultrasound guided injections for hip pain (trochanteric bursitis and osteoarthritis of the hip)

● Consultant if

outside of policy

Patellar Resurfacing as part of total knee replacement surgery ● Consultant

Spinal manipulation for the treatment of chronic, non-specific low back pain

● GP

Spinal Surgery (spinal fusion or discectomy) for the treatment of chronic non-specific low back pain

● GP

Referral for Hip Joint Replacement (Revision) Surgery ●

Consultant to refer to Specialist Orthopaedic

Centre

Referral for Knee Joint Replacement (Revision) Surgery ●

Consultant to refer to Specialist Orthopaedic

Centre

Transforaminal epidural injections for sciatica (diagnostic & therapeutic use)

● GP

Transforaminal epidural injections for sciatica (diagnostic use) ● GP

Treatment of bunions (hallux valgus) ● GP

Trigger finger surgery ● GP

Vertebroplasty and Kyphoplasty (in cases which do not meet NICE TA

279) ●

Consultant if outside of the NICE

TA





Approval

Funded Subject to

Audit

Funding application

required from Urology

Male Circumcision ●

GP

Erectile Dysfunction treatments - Including drugs sildenafil, vardenafil, tadalafil – within policy

●

GP if patient request outside of

criteria

Erectile Dysfunction treatments - Including: Erectile pumps/devices, the drugs sildenafil, vardenafil and tadalafil outside of policy and psychosexual interventions

● GP

Penile prosthesis / enlargement ● GP

Penile Rehabilitation following prostate surgery ● Consultant

Vasectomy & Reversal of Vasectomy ●

GP if patient request outside of

criteria

Vascular Surgery

Varicose Veins ●

GP




Process for managing restricted procedures, treatments and interventions This document includes the absolute criteria which must be met in order for the patient to be treated and the associated charges to be paid by Berkshire West Federated CCGs. It is important to note that the clinical case for an individual’s treatment should be assessed on its own merits and if a patient does not meet the criteria for funding an application can be made via an Individual Funding Request. The NHS Confederation document "Priority setting: managing individual funding requests", drafted for Primary Care Trusts in 2008, gives a clear definition of an individual funding request as follows:- "An Individual Funding Request (IFR) is a request to a CCG (formerly PCT) to fund healthcare for an individual who falls outside the range of services and treatments that the CCG (formerly PCT) has agreed to commission. There are several reasons why a CCG may not be commissioning the healthcare intervention for which funding is sought.

It might not have been aware of the need for this service and so has not incorporated it into the service specification

It may have decided to fund the intervention for a limited group of patients that excludes the individual for whom the request is made

It may have decided not to fund the treatment because it does not provide sufficient clinical benefit and/or does not provide value for money

It may have accepted the value of the intervention but decided it cannot be afforded in the current year

Such requests should not be confused with

Decisions that are related to care packages for patients with complex healthcare needs which include Continuing Health Care packages of care.

The above list is not exhaustive and is at the sole discretion of the Commissioners. Where patients do not meet criteria in the Amber category or are under the Red category Individual Funding Requests will usually be considered on the basis of ‘exceptionality’. A guide to what constitutes ‘exceptionality’ or ‘exceptional health need’, can be found here: http://www.fundingrequests.cscsu.nhs.uk/wp-content/uploads/2013/10/Exceptional-Health-Need-guide-for-patients-and-clinicians-April-2013.pdf Central to the CCG’s consideration of IFRs is the question: “Why should this treatment be provided for this patient, when it would not be funded for other patients who have the same, or a substantively similar, condition?” If funding is to be agreed for the proposed treatment, there must be some unusual or unpredictable or unique factor about the patient’s clinical circumstances, which suggests that:

the presentation/effect of the condition in the patient differs significantly from that found in the general population of patients with the condition

and, as a result,

the patient is likely to gain significantly more benefit from that treatment than might generally be expected for these patients.

http://www.fundingrequests.cscsu.nhs.uk/wp-content/uploads/2013/10/Exceptional-Health-Need-guide-for-patients-and-clinicians-April-2013.pdf





In addition to this: There should be sufficient evidence of the effectiveness of the treatment in bringing about the expected benefit for the patient. IFRs must be supported by a summary statement of evidence for the proposed treatment. NB: It is the requesting clinician’s responsibility, where relevant, to set out the case for an exception to be made. Please note: It is not possible to predict in advance what might provide a basis for exceptional funding, given the individual nature of each patient’s clinical circumstances. Meeting the accepted indications for a treatment does not, in itself, provide a basis for an exception. The fact that a patient is likely to respond to the requested treatment does not, in itself, provide a basis for an exception. Non-medical or social factors will rarely be considered as a basis for an exception. Social value judgements will not be considered as a basis for an exception. For a further explanation of exceptionality, please refer to the UK Faculty of Public Health document available at http://www.fph.org.uk/policy_reports (accessed 15/01/15) and


http://www.fph.org.uk/policy_reports






Figure 1 – Process for managing policies.

Berkshire West CCGs process for restricted treatments, procedures and interventions

Document that patient meets

criteria (proforma / case notes)

Treat Patient

Berkshire West CCGs audit and

review

Treat Patient

Treat Patient within timescale

6 months for procedures

12 months for drugs

Prior approval

considered by IFR

Treat Patient within timescale

6 months for procedures

12 months for drugs

Approved by IFR

Criteria met

Approved by IFR

Rejected

Check against policy criteria

GREEN

Refer Individual Funding Request to berkswest.ifrrequests

@nhs.net for consideration

RED

Seek prior approval from

[email protected]

AMBER

Does not meet

criteria

Referral arrives into Provider for a specific treatment / procedure

/ intervention/ drug

RED or Amber procedure with no IFR Prior approval

GREEN procedure outside of criteria

OR Retrospective funding

request (these will not be paid)

Approval must be obtained prior to First

OPA

REJECTED - back to referrer explaining

why

Not treated within relevant

timescale

NO

Declined

OPA for consultant’s opinion only can take place to determine treatment.

If treatment required is covered by the IFR policies for either RED or Amber or GREEN the

following process must be followed

NO

Referral arrives into Provider for a Consultants opinion only

mailto:[email protected]







Description of Prior Approval Process – All Providers

N.B. For clinically urgent requests which require Prior approval there is a ‘fast-track’ process which manages these requests within 48 hours of receiving a complete case. Therefore these will not delay clinically urgent treatments where the patient meets the criteria. This process applies for referrals into All Providers for restricted procedures, treatments and interventions outlined in Table 1. The process is:

1. Check the procedure is on the list (Table 1).

2. Check the policy for this procedure and assess the patient against the policy as per the categories below:

3. If prior approval is in place for red / amber categories or if patient meets criteria for green

patient can be invited for First Outpatient Attendance for assessment only. PLEASE NOTE: Where consideration is required for assessment of the patient’s health needs (and can only be determined by the Consultant in an outpatient assessment) then the patient should be invited for an assessment for an opinion only.

4. Decision made to clinically proceed based on initial assessment: No – Reject back to referrer explaining why Yes – Proceed

5. What process is followed for the required procedure / treatment, check is it Red, Amber or Green:

6. Red Policies – These procedures are not commissioned by Berkshire West CCGs. The clinician can apply for IFR if they believe the patient has extenuating circumstances and will benefit from procedure / treatment /intervention.

RED Red procedures without Individual Funding Requests must not be treated as they are not routinely commissioned. Reject Referral and send back to referrer explaining why.

AMBER

Check prior approval has been granted. If yes, proceed.

If no apply for IFR

GREEN Check criteria. If patient is outside of criteria. Reject referral and send back to referrer explaining why or you have the option to apply for IFR

RED Clinician believes patient has extenuating circumstances, exceptional health need and completes an Individual Funding Request to [email protected] for necessary approval and funding. If IFR rejected, patient referred back to referrer. Where IFR approved, proceed to treat.

AMBER

Prior approval required from BWCCGs. Clinician completes form detailing need for treatment and required procedure/ dosage or regimen to [email protected]. Where prior approval granted, proceed to treat. Where prior approval rejected, refer back to referrer explaining why

GREEN Check criteria. If patient is outside of criteria. Reject referral and send back to referrer explaining why. If believe patient has extenuating circumstance and exceptional health need, clinicians to apply for IFR. If patient meets the criteria, proceed with treatment documenting how patient meets criteria (proforma / patient notes). Berkshire West CCGs to audit and review compliance






7. Amber Policies – Written communication must be submitted to the IFR Team on behalf of

the BWCCGs at [email protected] for prior approval completing the appropriate proforma and explaining the patients need for treatment. The team will respond within 3-5 working days of the decision being made.

Approved - Where patients are approved, proceed with treatment. Providers must treat patients within 6 months of approval date for procedures/interventions or 12 months of approval for drug treatment.

Not Approved – Where patients are not approved DO NOT proceed with treatment and refer back to original referrer explaining why with necessary management plan.

8. Green Policies - Does the patient meet the criteria within the policy?

No – DO NOT treat. If the patient does not meet the criteria in the policy, BWCCGs will not fund the procedure. Clinician can apply for IFR if believes patient has extenuating circumstances and will benefit from procedure / treatment/ intervention. Otherwise refer back to original referrer Yes – Proceed with treatment. Document in proforma / patients notes where criteria have been met according to the individual policy. PLEASE NOTE: Retrospective funding will not be considered or agreed.

Process Funding Timelines

a. For clinically urgent cases these will be managed within a 48 hour notice period. These do not include those cases which are sent through due to an operation deadline.

b. The IFR Service will log all cases received within 2 working days unless where Providers have logged the case via the Blueteq Provider Portal.

c. All provider applications for Red and Amber procedures will receive a response within 15 working days (reduced to 10 working days for Blueteq provider applications). This may include notification that the case needs to be reviewed at clinical triage or case review committee. The Provider can treat the patient and the commissioner will be liable for the cost, where delay beyond these periods is evidenced and a full and complete case has been received by the IFR/Prior Approval Service prior to the operation date. Please note: Providers must not list patients for procedures where there is a clear criteria which the patient must meet. Those patients should be aware that funding could be declined by the IFR Service so as to manage patient expectation more appropriately.

Payment The Provider must submit a prior approval number for any Red or Amber patient treatments for procedures not normally funded, to attract payment for the procedure. Procedures denoted as ‘green’ do not require prior approval and are subject to regular commissioner audit to secure payment. The provider must ensure that the patient meets the criteria in full and this can be evidence when the case is audited.


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