The CCG Policy does not define patient management pathways but rather specifies arrangements for access to NHS funding.
- All healthcare professionals working in the local NHS system and subject to West Hampshire CCG contracts are expected to be aware of and operate within the limits of the above Policy.
- This requires that they work together as referrers and providers to implement the Policy and help patients to understand the arrangements in place. This will ensure that their patients obtain NHS funding where this is available, either through prior approval or individual funding request (IFR).
- Where the patient clearly meets the criteria and the decision is to refer for a specific treatment or procedure, primary care clinicians are expected to engage in the prior approval process before referral. Where prior approval is received, the code should be included with the referral.
- Where the patient clearly doesn’t meet the criteria for a restricted treatment or procedure, we would recommend that other management options are considered and a wasted referral avoided, saving time and inconvenience for all parties.
- Where there is uncertainty or the GP needs the support of a specialist opinion all available information supporting the treatment criteria should be included with the initiating referral.
- Where funding is not available, then the patient should be made aware of this and if necessary directed to the IFR or CCG appeals process. (leaflet available)
Restricted Treatments and Procedures
The current procedures/treatments and interventions can be broadly classified into three categories:
- RED: Excluded – procedures not routinely funded by The Commissioner (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 Service who manage these requests on behalf of the Commissioner
- GREEN: Procedures that are routinely funded subject to meeting certain criteria and not requiring prior approval – these will be subject to a ‘trust & verify’ process which will result in audits of an agreed sample of activity. (formerly known as threshold dependent procedures (TDP)
Red – Procedures not routinely funded (excluded)
These are procedures that will not be funded by the commissioning CCG due to a lack of evidence for clinical benefit, limited resource or the responsibility of specialised commissioning. Other management options should be considered. In exceptional circumstances, individual funding requests (IFR) may be made to the patient’s CCG for consideration. The IFR process, is outlined on the IFR website.
Amber – Procedures that require prior approval
For these procedures, it has been judged that the intervention is of sufficient value in terms of benefit and outcome when the patient meets the criteria, as outlined in the Policy and 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 providing the required detail. http://www.fundingrequests.cscsu.nhs.uk/
Green – Funded and Subject to a ‘Trust & Verify’ process incorporating verification audits.
For these procedures to be funded, the patient must meet the criteria as outlined in the Policy and on the Funding Requests website.
The CSU IFR Team can be contacted at: firstname.lastname@example.org