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DRAFT This is a joint policy developed and implemented by NHS Bournemouth and Poole, and NHS Dorset PRIOR APPROVAL BOOKLET June 2010 DRAFT POLICY TRAIL AND VERSION CONTROL SHEET: PRIOR APPROVAL BOOKLET Version: 1.0 Directors Meeting Approval PEC Pan-Dorset Intranet Commissioning Board Nov 2009 April 2010 Distribution Primary PCT Website Web April 2010 April 2010 Purpose To provide clear guidance advice and documentation to inform all providers of the Prior Approval Process and the Low Priority Procedures which the joint commissioners have developed. Status This is a dynamic document subject to change on a regular basis Policy Application All Providers Dorset. Author and Directorate Director of Acute Commissioning Approving Committee Trust Board Issue Date October 2009 Date of Next Review April 2011 and Commissioners and Primary across Care This Policy has been assessed using the October 2009 Equality Impact Assessment Tool as required by the Race Relations (Amendment) Act 2000 Responsibility for implementation All Acute Providers and Commissioners across Dorset Policy Statement Staff are required to ensure that they are aware of the contents of the Prior Approval Booklet and understand the implications for their work. This Booklet is supported by the Joint Commissioning Policy for Individual Treatment Requests which is a Dorset-wide agreed policy. This policy can be found on the PCT website. (www.bournemouthandpoole-pct.nhs.uk) * Directorate/Approving Committee/Year of Issue/Unique Identifier/Version Number DRAFT NHS BOURNEMOUTH AND POOLE NHS DORSET PRIOR APPROVAL BOOKLET Table of Contents Page PREFACE 1. INTRODUCTION 1 2. SACRAL NERVE STIMULATION 3 3. ICDs / CRT-D DEVICES – ADULT 11 4. AORTIC STENTS 17 5. KYPHOPLASTY 21 6. CATARACT 27 7. DRUGS 35 NICE 37 Non NICE 37 8. LOW PRIORITY PROCEDURES 43 9. INDIVIDUAL TREATMENT REQUEST FORM 54 DRAFT INTRODUCTION NHS BOURNEMOUTH AND POOLE NHS DORSET PRIOR APPROVAL BOOKLET 1. INTRODUCTION 1.1 NHS Bournemouth and Poole and NHS Dorset aim to commission high quality clinical care within finite resources. Care and treatment is commissioned on behalf of the whole population, and access is based on healthcare need, evidence and national guidelines where available. 1.2 NHS Bournemouth and Poole and NHS Dorset commissioners have responsibility for managing an overall commissioning budget. It is imperative that all commissioning decisions are based upon need and planned in a systematic and clear way that will ensure effective financial control. The commissioners’ responsibility is to ensure that commissioning decisions ensure equity in the overall use of healthcare resources for the whole population. 1.3 NHS Bournemouth and Poole and NHS Dorset are introducing a Prior Approval Process for a range of high cost procedures/devices for individual patients provided at all providers. This is in line with the DH guidance within the National Contract. 1.4 Following consultation with clinicians it has been agreed that high cost NICE/ locally recommended and commissioned drugs excluded from PbR tariff will be retrospectively reviewed on a monthly basis by the commissioners to ensure that prescribing is appropriate. 1.5 All non NICE drugs and the use of NICE approved/ locally recommended and commissioned drugs for patients who do not meet the appropriate criteria will require Prior Approval. 1.6 NHS Bournemouth and Poole and NHS Dorset have also identified a list of low priority procedures which they will no longer fund at any provider unless the patient is in a predefined sub-group (as defined in the policy) or have clinically exceptional circumstances. 1.7 Exceptionality means that there are clear clinical reasons why the individual would be expected to benefit more from this procedure than the general population with the same condition, for whom this procedure is considered low priority and is therefore not normally funded. Evidence to support exceptionality must be clinical, must be from a reputable source and must be submitted by the applying clinician. 1.8 Exceptionality cannot be based upon an individual’s social or personal circumstances. 1.9 This booklet contains a list of the procedures/devices for which the commissioners require Prior Approval and the appropriate patient pathways and/or documentation. Where a procedure/device specific Prior Approval Proforma is not supplied please use the generic Individual Treatment Request Form found on page 54 – 59. 1 1.10 The detailed policy supporting the commissioner decision is the Joint Commissioning Policy for Individual Treatment Requests, developed by NHS Bournemouth and Poole and NHS Dorset, which includes the Prior Approval Process. This policy sets out how the commissioners handle a range of requests received for interventions and drugs from clinicians. This is available on the NHS Bournemouth and Poole and NHS Dorset websites. http://www.bournemouthandpoole.nhs.uk http://www.dorset.nhs.uk 1.11 The Joint Commissioning Policy describes how the commissioners will handle such requests, in line with clear commissioning principles, quality standards and procedures. In particular, it aims to establish a transparent process that is committed to making fair and robust decisions as to the allocation of NHS resources. To do this, the process must consider the healthcare needs of the patient, the evidence relating to clinical effectiveness and cost-effectiveness, how the request fits with other local priorities, and the impact on aspects such as the quality of life for the patient. See websites. http://www.bournemouthandpoole.nhs.uk http://www.dorset.nhs.uk 1.12 On the matter of Choice “The Choice at Referral Guidance Framework 2007/8” indicated the impact of free choice in elective care. It is important to note that patients who wish to choose a service not commissioned for the local population and not listed on the national menu will still need their local commissioners to agree funding. 1.13 NHS Bournemouth and Poole and NHS Dorset recognise that there may be occasions when a patient is put forward for Prior Approval and may have good clinical reasons for being treated as an exception. In such cases the requesting clinician must provide further information to support the case for this being considered as an exception. 1.14 It is important to note that if a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional. 1.15 Clinicians, or patients with the support of their responsible clinician, wishing to appeal against a decision with respect to an individual case must notify the respective commissioners, in writing as per the policy. This appeal must be received within four weeks of receipt of the correspondence setting out the decision of the commissioners. The commissioners will acknowledge requests for appeals within seven working days. 1.16 It is important to note that the appeals panel will not consider new information in support of a case. If new clinical information becomes available prior to the Appeals Panel, the Individual Cases Team should be asked to reconsider the case in the light of this. It is the responsibility of the referring clinician, not the patient, to ensure that all necessary information is provided on the case. 1.17 The Appeals Panel chair will write to the clinician, with a copy to the patient within seven working days with the Panel decision. 1.18 It is anticipated that this process will enable the commissioners and providers to work together more effectively to make best use of our resources. 1.19 This booklet is only applicable for NHS Bournemouth and Poole and for NHS Dorset patients. For all other patients the providers will need to refer to the patients respective commissioners webpages to determine their policies. 2 SACRAL NERVE STIMULATION - PATHWAYS 3 4 Re: Sacral Nerve Stimulation It has been agreed that a Sacral Nerve Stimulation Service will be funded by NHS Bournemouth and Poole and NHS Dorset and provided by Poole Hospital NHS Foundation Trust. The pathway enclosed has been developed jointly between the two commissioning organisations and Poole Hospital, with clinical involvement, in order to address a local need for this service. The commissioners will make funding available on a named patient basis. Funding will only be available for patients who meet the NICE criteria and who have followed the agreed pathway. We anticipate that this will be in the region of ten patients in total for both commissioners per annum. Prior approval must be sought for a temporary implant from the relevant NHS commissioning body using the enclosed proforma. It is understood that it is likely that around 60% of patients who trial a temporary implant will be assessed as suitable for a permanent one. Where a patient has been approved to undergo a trial, the relevant commissioner should be notified of the outcome and whether the patient will be proceeding to a full implant before this occurs. It has been agreed that both commissioners will be included in the audit process and be given full access to outcomes data on a six-monthly basis. 5 NHS DORSET NHS BOURNEMOUTH AND POOLE POOLE HOSPITAL NHS FOUNDATION TRUST PATHWAY FOR SACRAL NERVE STIMULATION FOR THE TREATMENT OF FAECAL INCONTINENCE Primary Care Interface GP referral to: Local Primary Care Continence Service for assessment: Consider Symptom review & assessment of desired outcome Abdominal, rectal and perineal examination & urinalysis Assessment of manual dexterity Supply of continence products according to clinical need Discharge patient back to GP if no further treatment needed. Initial treatment from Primary Care Continence Service including, as appropriate: Offer treatments Advice on diet and toilet access Implementation of Bowel training programme Review of medication Instruction on Pelvic Floor and Anal Sphincter exercises Management of faecal impaction Treatment ineffective – refer on to specialist management service in secondary care service 6 SACRAL NERVE STIMULATION PATHWAY – STAGE 2 Secondary Care Interface Specialised Management by designated Pelvic Floor Dysfunction specialist clinician within acute Trust including as appropriate: Consider assessment: o Ano-rectal physiology studies o Endo-anal ultrasound o Defaecating Protogram Consider conservative measures Biofeedback Electrical Stimulation Rectal Irrigation Bowel Retraining Discharge patient back to GP if no further treatment needed Treatment unsuccessful Discuss with suitable patients Sacral nerve Stimulation as a treatment option ensuring that patients are aware, among other aspects, of: Any associated risks Success/failure rate of procedure Phases of the procedure (temporary trial prior to permanent implant), including explanation of conversion rates/success rates Patient wishes to proceed with Sacral Nerve Stimulation PHT contact patients’ PCT for prior approval. Approved Not approved PHT list patient for SNS procedure Return patient to GP’s care 7 SACRAL NERVE STIMULATION PATHWAY – STAGE 3 Secondary Care Pathway Phase 1: Trial or diagnostic phase. Temporary external peripheral nerve stimulator attached. Effectiveness tested over 2-3 week period Trial phase successful Consider repeat SNS evaluation. (once only) Trial phase unsuccessful Phase 2: Permanent implant inserted. Time delay to be encouraged between temporary and permanent implant – can be up to 3 months - to look at rebound effect and assess efficacy. If repeat SNS is unsuccessful or not indicated consider surgery for formation of stoma AC to co-ordinate patient education on use of implant. Follow up care to be provided at regular intervals in OPD as follows: 6 weeks, 3 months, 6 months & 12 months 8 NHS DORSET NHS BOURNEMOUTH AND POOLE PRIOR APPROVAL FORM FOR SACRAL NERVE STIMULATION PROCEDURE On completion, please email to a secure nhs.net email address or safe haven fax. CONTACT INFORMATION 1. Trust Name and Address 2. Applicant Details: Name and Designation: Tel: Email: 3. Patient Details: Name: DoB: NHS Number: Registered GP name and PCT: Registered GP Postcode: Registered Consultant: Referred to – with date: Referred from – with date: Is the patient aware of this request? Delete as appropriate: Yes/No INTERVENTION REQUESTED: 4. Patient Diagnosis (for which intervention is requested) SACRAL NERVE STIMULATION 5. Has the agreed pathway been followed? Delete as appropriate: Yes/No 6. Does the patient meet current NICE guidance for the intervention? Delete as appropriate: Yes/No 7. Is the patient aware of phases of the process, ie. temporary to permanent implant, dependent on effectiveness, and alternative management if implant is unsuccessful. 8. Date request for prior approval submitted: 9. Form submitted to: 10. What number request is this referral? Delete as appropriate: Dorset PCT/ Bournemouth and Poole PCT/ Other 9 PRIOR APPROVAL FORM FOR SACRAL NERVE STIMULATION PROCEDURE Page 2 Section below to be completed once Prior Approval given by PCT and submitted on completion of treatment. PATIENT PROCESS: For record once prior approval confirmed 10. Date prior approval received from PCT: 11. Dates for the following: Placed on waiting list: Date of trial for SNS (diagnostic stage): Delete as appropriate: Yes/No Successful: Delete as appropriate: Yes/No Proceed to permanent implant stage: Date of permanent implant: Outcomes: ie. Level of improvement experienced by patient. 12. Date submitted final completed form to PCT: 10 ICD AND CRT D INDIVIDUAL CASE FUNDING 11 12 ICD and CRT D Individual Case Funding NICE guidance exists in relation to the use of ICD and CRT: Implantable Cardioverter Defibrillators for Arrhythmias (TA95) Cardiac resynchronisation therapy for the treatment of heart failure (TA120) All requests for ICD or CRT D require prior approval. A policy in relation to the use of ICD and CRT-D in patients who fall outside of NICE guidance (including patients with non-ischaemic dilated cardiomyopathy) is being considered by the PanDorset Technologies Forum. In the interim, there is an expectation that all requests which fall outside of NICE guidance will be considered by the Individual Cases Panel. The commissioners will require the following retrospective information to be provided on a monthly in relation to cardiac devices: A split between elective and non-elective activity A split between type of cardiac device Details of the device model and the respective price Patient details to enable verification of GP registration For elective cases, a cross –reference to prior approval The commissioners will require this information for both elective and non-elective activity and this requirement will be part of the contractual arrangements with all acute providers of these services. 13 NHS BOURNEMOUTH AND POOLE NHS DORSET ICD & CRT-D INDIVIDUAL CASE FUNDING AUTHORISATION REQUEST FORM Please complete all relevant sections then email to a secure nhs.net email address or safe haven fax CONTACT INFORMATION 1. Trust Name and Address 2. Applicant Details Name and Designation: Tel: Email: 3. Patient Details Name: Hospital ID number: DoB: Registered Consultant: Registered GP name and PCT: Registered GP postcode: Has the GP been made aware of this request and had an opportunity for input? If Yes please give date and details: Delete as appropriate: Yes/No INTERVENTION REQUESTED (NB: Intervention refers to requested treatment, investigation, etc) 4. Patient Diagnosis (for which intervention is requested) 5. Details of intervention for which funding is requested: i.e. ICD or CRT-D 14 CLINICAL EVIDENCE 6. For an ICD device the patient must fulfil the criteria as specified in NICE Guidance: Implantable Cardioverter Defibrillators for Arrhythmias Technology Appraisal 95 – Issue Date Jan 2006 (TA95) Please specify clinical indications for this intervention as below: Delete as appropriate: If Yes, give details For Secondary prevention: - has survived a cardiac arrest due to either ventricular tachycardia (VT) or ventricular fibrillation (VF) Yes/No - spontaneous sustained VT causing syncope or significant haemodynamic compromise Yes/No - sustained VT without syncope or cardiac arrest with an associated reduction in ejection fraction (LVEF of less than 35%) (no worse than class III of the New York Heart Association functional classification of heart failure). For primary prevention: - a history of previous (more than 4 weeks) myocardial infarction and: either left ventricular dysfunction with an LVEF of less than 35% (no worse than class III of the New York Heart Association functional classification of heart failure), and non-sustained VT on Holter 24-hour electrocardiogram monitoring, and inducible VT on electrophysiological testing or left ventricular dysfunction with an LVEF of less than 30% (no worse than class III of the New York Heart Association functional classification of heart failure)and QRS duration of equal to or more than120 milliseconds Yes/No Yes/No Yes/No Yes/No QRS Duration: - a familial cardiac condition with a high risk of sudden death, including long QT syndrome, hypertrophic cardiomyopathy, Brugada syndrome or arrhythmogenic right ventricular dysplasia (ARVD), or have undergone surgical repair of congenital heart disease. Yes/No 7. For a CRT-D device the patient must fulfil the criteria for both an ICD ( as TA95 above) and CRT as specified in NICE Guidance: Delete as appropriate: If Yes, give details Cardiac resynchronisation therapy for the treatment of heart failure Technology Appraisal 120 – Issue Date May 2007 (TA120) Please specify clinical indications for this intervention as below: Yes/No The patient fulfils the criteria for ICD: and They are experiencing or have recently experienced New York Heart Association (NYHA) class III-IV symptoms Yes/No Yes/No They are in sinus rhythm They have a left ventricular ejection fraction of 35% of less They are receiving optimal pharmacological therapy Yes/No Yes/No 8. If the request for device falls outside of current NICE guidance please outline the clinical indication for treatment: 15 MEDICAL HISTORY 9. Please give details of previous medical history and co-morbidities: 10. Please summarise the current status of the patient in terms of quality of life, symptoms and life expectancy. 11. Are there any additional clinical factors that need to be considered not already included? Yes/No If Yes, give details PATIENT PROCESS 12. Has the treatment been discussed with patient? Delete as appropriate: Yes/No 13. Is the intervention routine or sooner? Note Patients should not be put on waiting list unless approved for treatment. 15. Date form completed: 16 AORTIC STENTS 17 18 AORTIC STENTS Following discussions between NHS Bournemouth and Poole and NHS Dorset Commissioners with clinical staff at The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust it has been agreed that elective endovascular aneurysm repair (EVAR) meeting NICE guidance will not require prior approval. Commissioners will however require a monthly schedule detailing the type of stent, the stent cost, and the individual details reported within contractual arrangements for all EVAR meeting NICE requirements. Prior approval will be required for any EVAR which does not meet NICE guidance and commissioners will take all such requests to Individual Patient Panels. Requests for prior approval for EVAR not meeting NICE guidance should be submitted on the standard individual treatment request form on pages 45-50. We do not routinely commission elective or non elective Thoracic Endovascular Aneurysm Repair (TEVAR) or elective or non-elective Fenestrated Endovascular Aneurysm Repair (FEVAR) procedures. Commissioners will take all such requests to Individual Patient Panels. Commissioners will again require a monthly schedule detailing the type of stent, the stent cost, and the individual details of any TEVAR or FEVAR procedure reported within contractual arrangements. For all emergency / urgent TEVAR or FEVAR Commissioners will require post notification which must include type of stent, the stent cost, and the individual details as to why this procedure was undertaken. This will need to be reported within the contractual arrangements. Elective requests for and post notification of emergency TEVAR or FEVAR should be submitted on the standard individual treatment request form on pages 54-59. The exceptional circumstances for this intervention should be explicit within the documentation submitted. 19 20 KYPHOPLASTY 21 22 KYPHOPLASTY Management of vertebral compression factures Vertebral compression fractures (VCF) are a common cause of pain and disability. The majority of people are treated conservatively with analgesics, bed rest and bracing but a small percentage of people are left with persistent pain and limited mobility. Balloon Kyphoplasty Balloon Kyphoplasty (BKP) is indicated for painful vertebral compression fractures in the lumbar or thoracic region, due to primary osteoporosis, secondary osteoporosis, osteolytic lesions due to multiple myeloma or bone metastasis or trauma. It is a minimally invasive procedure designed to reduce and stabilise the fracture, correct spinal deformity, prevent new fractures and provide immediate and sustained pain relief and improved quality of life. NHS Bournemouth and Poole, and NHS Dorset, have agreed a Dorset-wide service to be commissioned from RBCHFT for individual patients with prior approval from the relevant commissioner, based on a multi-disciplinary team decision and in line with pathway. We would anticipate this to be in the region of 30 procedures per annum. The generic form on pages 54-59 should be used when requesting prior approval for kyphoplasty. 23 24 NHS BOURNEMOUTH AND POOLE AND NHS DORSET IN PATIENT PATHWAY Kyphoplasty Assessment ACUTE BACKPAIN PROMPTING ADMISSION Inclusion criteria Suspicion this is due to osteoporotic vertebral fracture Assessment to include MAKE DIAGNOSIS 1. Confirmation of suspected vertebral fracture (xray) 2. Confirm diagnosis of osteoporosis OP 3. Physical examination suggests vertebral fracture is the symptomatic lesion 4. Senior clinical opinion a. Is conventional medical management optimised? Including analgaesia and osteoporosis Rx b. Is the patient likely to have a prolonged in patient episode due to the condition (>2 weeks)? c. Is patient fit enough for kyphoplasty. (Prone general anaesthesia). Is the patient willing to be considered for kyphoplasty? Kyphoplasty 1. Pain and disability non-reponsive to CMM and 2. Pain in localised to fractured vertebra site – x-ray shows evidence of vertebral collapse and 3. T2/STIR MRI scan shows evidence of oedema at painful level and 4. Patient willing and fit enough to consider kyphoplasty and GA and 5. Clinical presentation does not indicate other causes of pain and is not otherwise contraindicated for example: - infection - absence of increased signal on T2/STIR MRI - spinal cord / neurological compromise - extensive posterior element involvement by fracture a,b and c - YES Refer for Kyphoplasty assessment (RBH radiology) Dr A Pope x4443 fax 704424 DO NOT undertake kyphoplasty If inclusion criteria NOT met 25 Kyphoplasty MDT If inclusion criteria met 1. Examination investigation and confirmation the patient meets agreed criteria 2. Education and informed consent 3. PCT approval of case If NOT appropriate following MDT assessment 26 CATARACT 27 28 CATARACT 1. INTRODUCTION AND SCOPE 1.1 This policy describes the access criteria in respect of the surgical removal of cataract(s). 1.2 All requests for cataract surgery outwith this policy will only be considered in accordance with the Joint Commissioning Policy for Individual Treatment Requests. 2. DEFINITIONS 2.1 Cataract refers to any opacity in the lens of the eye resulting in the impairment of vision or blindness. 3. ACCESS CRITERIA 3.1 It is expected that the majority of suspect cataract(s) will be detected initially following sight testing or eye examination, under either NHS or private contract, undertaken by a community optometrist. 3.2 Whilst community optometrists preserve the right to refer their patients direct to an appropriate Hospital Eye Service, in practice community optometrists should inform the patient’s registered GP of the detection of suspect cataract following sight testing or eye examination. 3.3 Some patients with suspect cataract(s) may present initially direct to their registered GP. In such cases, the GP should require that their patient is referred for a sight test or eye examination, including the measurement of visual acuity, to be undertaken by a community optometrist. 3.4 The patient’s GP will require the results of the sight test or eye examination in order to; 3.5 determine if the patient meets the access criteria for cataract surgery; determine if the patient, having been accessed by the GP as meeting the access criteria, consents to a referral for possible cataract surgery and is willing to accept surgery if offered; determine if, in circumstances where the patient does not meet the access criteria, there exist ‘exception circumstances’ to support the patient’s appeal in accordance with the Joint Commissioning Policy for Individual Treatment Requests; All requests for the surgical removal of cataract(s) will only be supported by the commissioning Primary Care Trusts where the patient’s best corrected visual acuity, as assessed by high contrast testing (Snellen), is; Binocular visual acuity of 6/10 or worse for drivers; OR, Binocular visual acuity of 6/12 or worse for non-drivers; OR, Monocular visual acuity of 6/18 or worse irrespective of the visual acuity of the other eye; OR, 29 the patient’s expressed wish or requirement is to continue driving but the patient does not meet the Driving and Licensing Authority (DVLA) minimum sight requirements; 3.6 In all cases where the access criteria are met, prior to initiating a referral for possible cataract surgery, the GP should have discussed with the patient the potential benefits and risks of cataract surgery, have obtained clear and informed consent from the patient to proceed with a referral, have obtained an assurance that the patient would accept cataract surgery if offered. 3.7 For reference purposes only, the DVLA minimum sight requirements are as follows. The full version of the DVLA Medical Standards for Fitness to Drive is accessible at www.dft.gov.uk/dvla/medical. 3.8 All Vehicles: able to read in a good light (with the aid of glasses or contact lenses if worn) a registration mark fixed to a motor vehicle and containing letters and figures 79.4mm high and 50mm wide at a distance of 20.5m. This corresponds to a binocular visual acuity of approximately 6/10 on the Snellen chart. NB: In the presence of cataract glare may prevent the ability to meet the number plate requirement, even with apparently appropriate acuities. Group 2 Vehicles (LGV/PCV): the visual acuity, using corrective lenses if necessary, must not be worse than 6/9 in the better eye or 6/12 in the other eye. Also, the uncorrected acuity in each eye MUST be at least 3/60. General Guidance: the Royal College of Ophthalmologists has also issued the following advice to the DVLA ‘The minimum visual field for safe driving is a field vision of at least 120°on the horizontal meridian measured by the Goldmann perimeter on the III4e settings (or equivalent perimetry). In addition, there should be no significant field defect in the binocular field which encroaches within 20°of fixation either above or below the horizontal meridian. By this means, homonymous or bitemporal defects which come within 20°of fixation, whether hemianopic or quadrantanopic, are not accepted as safe for driving. Isolated scotomata represented in the binocular field near to the central fixation area are also inconsistent with safe driving’. In all cases, GPs should provide patients with a copy of the most recent edition of the following patient information leaflet, published by the Royal College of Ophthalmologists, prior to any decision to refer for cataract surgery; Understanding Cataracts – www.rcophth.ac.uk/docs/publications/patient-infobooklets/understandingcataracts.pdf. 4. EXCEPTIONS TO THE ACCESS CRITERIA 4.1 The following categories of patient or ophthalmic conditions are exempt from application of the access criteria as set out in 3.5 above and may be referred for possible cataract surgery; Patients of 18 years of age or less at the date of referral; Patients with anisometropia presenting with suspect cataract(s). 30 NHS DORSET NHS BOURNEMOUTH AND POOLE PATHWAY FOR THE SURGICAL REMOVAL OF CATARACT Discharge Patient does not wish to have surgery General Practitioner Community Optometrist Application of Access Criteria Patient does NOT meet Access Criteria but requests consideration of ‘exceptionality’ Complete Prior Approval Form for cataract surgery Patient meets Access Criteria OR has Prior Approval submit form to relevant commissioner offer patient choice of Acute Providers of cataract surgery Prior Approval Request NOT granted Refer to Acute Provider Prior Approval Request Granted 31 32 NHS DORSET NHS BOURNEMOUTH AND POOLE PRIOR APPROVAL FORM FOR CATARACT SURGERY On completion, please email to: [email protected] OR fax to: Safe Haven Fax: 01202 541905 OR fax to: Safe Haven Fax: 01305 361176 (for NHS Bournemouth and Poole) [email protected] (for NHS Dorset) CONTACT INFORMATION 1. Trust Name and Address 2. Applicant Details: Name and Designation: Tel: Email: 3. Patient Details: Name: DoB: NHS Number: Registered GP name and PCT: Registered GP Postcode: Registered Consultant: Community Optometrist name & Post Code Referred to – with date: Referred from – with date: Delete as appropriate: Yes/No Is the patient aware of this request? INTERVENTION REQUESTED: 4. Patient Diagnosis (for intervention is requested) CATARACT SURGERY which 5. Has the agreed pathway been followed? Delete as appropriate: Yes/No 6. Does the patient meet commissioner’s current cataract policy access criteria? Delete as appropriate: Yes/No 7. Is the patient aware of the risks and benefits of cataract surgery, and in receipt of relevant patient information literature? 8. Date request for prior approval submitted: 9. Form submitted to: 10. What number request is this referral? Delete as appropriate: Dorset PCT/ Bournemouth and Poole PCT/ Other 33 PRIOR APPROVAL FORM FOR CATARACT SURGERY Page 2 Section below to be completed once Prior Approval given by PCT and submitted on completion of treatment. PATIENT PROCESS: For record once prior approval confirmed 10. Date prior approval received from PCT: 11. Dates for the following: Placed on waiting list: Date of trial for SNS (diagnostic stage): Delete as appropriate: Yes/No Successful: Delete as appropriate: Yes/No Proceed to permanent implant stage: Date of permanent implant: Outcomes: ie. Level of improvement experienced by patient. 12. Date submitted final completed form to PCT: 34 DRUGS NICE AND NON-NICE 35 36 NICE/Locally recommended and commissioned drugs For selected high cost drugs excluded from the PbR tariff (see attached list) and for which there is either NICE guidance or locally recommended and commissioned treatment policies in place, providing the patient to be treated meets fully the specified criteria within the local policy or the NICE guideline, there is no requirement to obtain prior approval. However, the commissioners will expect detailed information on the patients treated including, patient’s NHS number, condition to be treated, drug used and how the patient meets the NICE/locally commissioned criteria (the form attached or a similar agreed form should be used). This information should be submitted as soon as possible after treatment is initiated; where more than one form has been completed these should be collated and submitted at the end of the month when the drug was initiated. The commissioners will only fund retrospectively those patients who fully meet the specified criteria. If a patient falls outside of the NICE/locally commissioned criteria then prior approval must be obtained. Non NICE drugs not routinely commissioned For those drugs not covered by NICE guidance and commissioned policies in place or for which considered/commissioned, prior approval must be treatment commences. This must be using the Treatment Requests. for which there are no locally agreed and a particular indication has not been obtained from the commissioner before standard application form for Individual Omalizumab Adults with Asthma require prior approval to be obtained before initiating treatment with Omalizumab. In the absence of NICE guidance/local policy children and adolescents will require individual patient panel approval prior to starting therapy. Botulinum Toxin Patients being considered for Botulinum Toxin for axillary hyperhydrosis require prior approval. Pemetrexed The requirement for prior approval to be obtained before initiating treatment with Pemetrexed for NSCLC (NICE TA 181) will remain in place until further notice. 37 38 NOTIFICATION OF HIGH COST EXCLUDED DRUGS To be completed by the prescribing clinician and sent to the respective Primary Care Trust. For NHS Bournemouth and Poole [email protected] For NHS Dorset [email protected]. Please complete BOTH sides of the form. Please note the Foundation Trust will not receive payment for the patient’s treatment if the form has not been completed in full. Payment will only be made if it has been confirmed that the patient meets the criteria specified by NICE or the Local Commissioning Policy. Payment will only be made for patients for whom a ‘Notification of High Cost Excluded Drugs’ form has been received. The commissioners will maintain a secure, confidential database of all patients treated and may from time to time request updates on the patient’s treatment. If for any reason a patient’s treatment is stopped the commissioners must be notified. 1. Patient Details NHS Number Patient Name Date of Birth Name of Consultant treating the patient and hospital base Name of patient’s GP WHO performance status (where applicable) 2. Diagnosis and Treatment Prescribed Diagnosis Drug treatment prescribed including dose/route/and frequency Indication; For oncology Please indicate whether the treatment is for example; first line, second line or third line Neo-adjuvant Adjuvant Concurrent chemo/radiotherapy Primary curative Primary Palliative Second line Third line 39 Non cancer Anticipated length of treatment (numbers of cycles/courses/months) Cost of treatment (per cycle/course /month) Proposed treatment review dates 3. NICE / Local Commissioning Policy Which NICE guidance applies How does this patient meet the NICE criteria? (Please specify fully according to the NICE eligibility criteria, how the patient meets the NICE criteria for treatment.) If no NICE guidance has been published is there an existing local policy agreed with commissioners If the answer to this is yes please specify which policy covers this treatment and how the patient concerned meets the eligibility criteria. Please note; If the answer is no Payment will not be made available via this route and an application should have been made to the individual treatment request panel. 40 High Cost Drugs Excluded from the PbR Tariff Requiring Notification of Use and Compliance with NICE Guidance or Local Commissioning Policies Drug Name Glatiramer Interferon alfa Interferon beta Natalizumab PbR category Immunomodulating Immunomodulating Immunomodulating Immunomodulating Botulinum toxin Torsion dystonias/other involuntary movements (includes botox and riluzole) Torsion dystonias/other involuntary movements (includes botox and riluzole) Riluzole Adalimumab Etanercept Infliximab Rituximab Certolizumab Teriparatide Ranibizumab Ustekinumab Bortezomib Cetuximab Docetaxel Trastuzumab Irinotecan Pemetrexed Oxaliplatin Dasatinib Erlotinib Imatinib Nilotinib Sunitinib Cytokine inhibitors Cytokine inhibitors Cytokine inhibitors Cytokine inhibitors Cytokine inhibitors Drugs affecting bone metabolism Cytokine inhibitors Oncology/Haematology Drugs Antineoplastic drugs Antineoplastic drugs Protein kinase inhibitors Protein kinase inhibitors Protein kinase inhibitors Protein kinase inhibitors Protein kinase inhibitors 41 Rituximab Alemtuzumab Interferon alfa Interferon beta Lenalidomide Thalidomide Fludarabine Trabectidine Cytokine inhibitors Drugs affecting the immune response Immunomodulating Immunomodulating Immunomodulating Immunomodulating Antihaemophilic Factor/von Willebrand Factor Complex Antithrombin III Drotrecogin alfa Factor IX Factor VII Factor VIIa (Eptacog alfa) Factor VIII Factor VIII inhibitor bypassing factor Factor XIII Fibrin sealants Fibrinogen Porcine Factor Protein C Prothrombin Complex Thrombin Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products Antifibrinolytic drugs/haemostatics blood products 42 LOW PRIORITY PROCEDURES 43 44 LOW PRIORITY PROCEDURES Schedule 14 Part 1: Treatment & Conditions not normally commissioned and /or funded by NHS Dorset and NHS Bournemouth and Poole The Commissioners consider that the efficacy of certain procedures is such that they will not normally be funded without prior approval. In addition there are certain procedures that the Commissioners consider should not normally be funded by the NHS. This schedule details a specified list of such procedures and (where required) the process for approval that should be followed. There may be a range of other areas where clinical opinion or commissioning priorities suggest that treatments or procedures should not be commissioned. REASON – Reflects the principal reason why the treatment or procedure is not normally funded. LPP Low Priority Procedures This group includes treatment or procedures where the evidence suggests the benefit to the patient may be small, where the likely cost outweighs the potential benefit, and/or where other treatments are deemed, through a transparent process, to be a higher priority for funding. Commissioning may be limited to approval in certain pre-defined sub-groups only, where these groups are likely to achieve greater benefit and/or balance of cost and benefit is within an agreed threshold. CP Care Pathway This group includes particular treatments or procedures which are considered as part of a clear care pathway. This ensures that less invasive and less costly alternatives that may be effective are tried first and that these particular treatments or procedures are commissioned only for patients for whom these alternative interventions have been unsuccessful. CEL Clinical Effectiveness in This group includes treatment or procedures where the Limited Groups evidence of effectiveness is generally available for certain clinical subgroups only and where we would therefore only commission the intervention for that subgroup. UCE Uncertain Clinical This group includes treatment or procedures where NICE Effectiveness (usually in Interventional Procedure Guidance) has indicated that there is limited evidence of clinical effectiveness and/or concerns about the safety of the treatment or procedure. We therefore do not commission these interventions SC This column identifies treatments or procedures where commissioning arrangements involve Specialised Commissioning with either the South West Specialised Commissioning Group and/or the National Specialist Commissioning Group and where these interventions may therefore only be available through specific, designated centres. 45 APPROACH TO APPROVAL 0 1 2 3 4 5 6 7 Not approved under any circumstances, usually where there is uncertain clinical effectiveness. If new evidence is submitted commissioners will reconsider this approach. Prior approval should be sought by primary care for all cases prior to referral into secondary care. Secondary care should not proceed unless evidence of approval is provided with the referral. Clinicians are urged to check the policy to determine criteria used in approval. Patients may require investigation in secondary care to determine whether they meet criteria for approval. Primary care should only refer patients who are likely to meet criteria, and should advise the patient, before referral into secondary care, that they will still need PCT approval prior to the relevant intervention being carried out. Secondary care should not proceed to intervention without prior approval, which may be sought by primary or secondary care. Clinicians are urged to check the policy to determine criteria used in approval. Patients may require referral into secondary care for advice and guidance or initial management with respect to their condition. Secondary care should not proceed to the relevant treatment or procedure without prior approval which should be sought by secondary care. Clinicians are urged to check the policy to determine criteria used in approval. Prior approval should be sought by secondary care for all cases prior to onward referral. The relevant treatment or procedure should not proceed unless evidence of approval is provided with the referral. Clinicians are urged to check the policy to determine criteria used in approval. Patients may require further investigation, advice or guidance in tertiary care to determine remaining management options. If these are likely to include relevant treatments or procedures secondary care should advise the patient, before referral into tertiary care, that they will still need PCT approval prior to the relevant intervention being carried out. Tertiary care should not proceed to intervention without prior approval, which may be sought by secondary or tertiary care. Clinicians are urged to check the policy to determine criteria used in approval. Patients who meet the policy/guidance do not require prior approval. Clinicians are urged to check the policy to determine those patients who meet criteria. For patients who do not meet the policy see ‘7’. Cases with exceptional clinical circumstances may be considered on an individual basis through the individual cases policy. Request may come from primary or secondary care. 46 1. Where the Provider receives a referral in relation to any of the procedures listed below, the Provider shall not treat the patient other than: where the patient’s condition is considered clinically urgent in the reasonable opinion of the Provider in which case the Provider will perform the procedure and will inform the Commissioner thereafter explaining why the procedure was considered urgent; or where the referral has previously been approved through the Commissioner’s Individual Cases process and is clearly marked as such; or Where the Commissioner’s Individual Cases Panel has previously referred a patient for review by the Provider, and in the reasonable opinion of the Provider the procedure is deemed clinically necessary (unless explicitly specified in letter from the Individual Cases Team/Panel); Where the patient falls into group 6 in the above table and meets criteria in the relevant policy for approval. 2. Where the Provider receives a referral for a procedure where the approach to approval is indicated as group 1 in the table below and which does not satisfy the conditions in paragraph 1 above, the Provider shall return the referral to the patient’s GP indicating the rank and that appropriate approvals should be sought. 3. Where the Provider receives a referral where the approach to approval is group 2 or 3 the Provider shall invite the patient for a chargeable outpatient appointment for the purposes of assessment and diagnosis. If it is then determined that the patient requires a relevant treatment or procedure, the Provider, in discussion with the GP, will ensure that appropriate approvals are sought. 4. Where the Provider carries out a procedure identified in this schedule in contravention of the conditions set out in paragraphs 1 to 4 above, the Commissioner will not fund the procedure. 5. The Provider and the Commissioners shall periodically review the operation and application of this schedule and will agree changes as appropriate to ensure its effective operation. 6. Relevant policies will be made available on the Commissioner websites. Forms to seek appropriate approvals are also available through the Commissioner websites and included at the end of this document. 7. Funding requests may be made through Individual Treatment Request Process for any individual patients with exceptional clinical circumstances but who do not meet the criteria for approval in this and related policy documents. 47 Reason Interventions not normally funded Guidance or Policy (hyperlinks to policies LPP 1. Abdominoplasty or Apronectomy Apronectomy / Abdominoplasty Policy CP 2. Bariatric Surgery Bariatric Surgery Policy LPP 3. Breast asymmetry surgery Breast Surgery Policy 1 LPP 4. Breast reduction surgery Breast Surgery Policy 1 LPP 5. Breast prosthesis removal or replacement Breast Surgery Policy 3 LPP 6. Inverted nipple correction Breast Surgery Policy 7 LPP 7. Cosmetic Mastoplexy Breast Surgery Policy 7 LPP 8. Mastopexy Breast Surgery Policy 7 LPP 9. Revision Mammoplasty Breast Surgery Policy 7 LPP 10. Gynaecomastia - Male Breast reduction surgery Breast Surgery Policy 7 CP 11. Hyperhidrosis treatment with Botulinum Toxin Care Pathway 3 CP 12. Sacral nerve stimulation Care Pathway 3 CP 13. Kyphoplasty Care Pathway 3 LPP 14. Cataract Surgery Cataract Surgery Policy 1 CEL 15. Complementary Therapy Complementary Medicines and Therapy Policy 1 LPP 16. Blepharoplasty Cosmetic Treatments and Procedures Policy 2 LPP 17. Face lift or brow lift Cosmetic Treatments and Procedures Policy 7 LPP 18. Laser hair depilation Cosmetic Treatments and Procedures Policy 7 LPP 19. Hair grafting / hair systems Cosmetic Treatments and Procedures Policy 7 LPP 20. Liposuction Cosmetic Treatments and Procedures Policy 7 LPP 21. Pinnaplasty Cosmetic Treatments and Procedures Policy 6 LPP 22. Removal of Tattoos Cosmetic Treatments and Procedures Policy 7 LPP 23. Removal benign skin lesions Cosmetic Treatments and Procedures Policy 1 to be established) SC ♦ Approach to Approval 7 1 Investigation of cause of gynaecomastia does not require prior approval If suspicious lesion clinician to proceed and notify the relevant commissioner afterwards. 48 Reason Interventions not normally funded Guidance or Policy (hyperlinks to policies LPP 24. Removal of lipomata Cosmetic Treatments and Procedures Policy LPP 25. Repair of lobe of external ear Cosmetic Treatments and Procedures Policy 7 LPP 26. Aesthetic facial procedures, chemical peels, dermabrasion, and laser treatment Cosmetic Treatments and Procedures Policy 7 LPP 27. Rhinoplasty Cosmetic Treatments and Procedures Policy 2 LPP 28. Thigh lift, buttock lift and arm lift, excision of redundant skin or fat Cosmetic Treatments and Procedures Policy 7 LPP 29. Circumcision for non medical reasons Cosmetic Treatments and Procedures Policy 7 Circumcision Policy 6 to be established) SC Approach to Approval 1 30. Circumcision for medical reasons LPP 31. Laser surgery for short sightedness Cosmetic Treatments and Procedures Policy 7 LPP 32. Orthodontic treatments of essentially cosmetic nature Cosmetic Treatments and Procedures Policy 7 LPP 33. Dental implants for cosmetic reasons Dental Implants Policy 1 CP 34. IVF/ICSI Fertility Policy 3 CP 35. Sperm Storage Fertility Policy 3 LPP 36. Reversal of female sterilisation Fertility Policy 7 CPP 37. Reversal of male sterilisation Fertility Policy 7 LPP 38. Functional Electrical Stimulation (FES) FES Policy 7 CP 39. Gender reassignment surgery Gender Reassignment Policy CEL 40. Elective Hyperbaric Oxygen Therapy Hyperbaric Oxygen Therapy Policy 7 CEL 41. Dilatation and curettage Low Priority Treatments and Procedures Policy 3 LPP 42. Ganglia Low Priority Treatments and Procedures Policy 7 CEL 43. Caesarean section for non-clinical reasons Low Priority Treatments and Procedures Policy 7 LPP 44. Apicectomy Low Priority Treatments and Procedures Policy 7 LPP 45. Removal of Asymptomatic Impacted Wisdom Teeth Low Priority Treatments and Procedures Policy 7 CEL 46. Myringotomy with/without grommets Surgical management of otitis media with effusion in children policy 2 49 ♦ 4 Reason Interventions not normally funded Guidance or Policy (hyperlinks to policies CEL 47. Tonsillectomy Tonsillectomy policy CEL 48. Varicose veins Varicose vein surgery policy 1 CP 49. Drug treatment for erectile dysfunction As per DH Guidance 3 CEL 50. EVAR NICE TAG 6 UCE 51. ICD and CRT-D NICE TAG 3 UCE 52. Scleral expansion surgery for presbyopia NICE IPG 070 0 UCE 53. Radiotherapy for age-related macular degeneration NICE IPG 049 0 UCE 54. Implantation of miniature lens systems for advanced age-related macular degeneration NICE IPG 272 0 UCE 55. Tubal Surgery NICE CG 11 0 UCE 56. Single-incision sub-urethral short tape insertion for stress urinary incontinence in women NICE IPG 262 0 UCE 57. Retrograde urethral sphincterotomy NICE IPG 167 0 CP 58. High cost drugs not included within the national tariff As per provider contract LPP 59. Consultant to consultant referral unrelated to referring condition Refer back to GP 4 CP 60. CPAP / BiPAP As per SIGN Guidelines No. 73 “Management of Obstructive Sleep Apnoea and Hypopnoea Syndrome in Adults” 3 UCE 61. FEVAR / TEVAR Local policy in development 7 CP 62. Penile Prosthesis Local policy in development 7 CP 63. Umbilical Cord Blood Collection and Storage Local policy in development 7 UCE 64. TAVI Not commissioned UCE 65. HIFU/Robotic Radical Prostatectomy Not commissioned 7 CP 66. Rectal Irrigation Not commissioned 7 to be established) 50 SC Approach to Approval 6 3/5 ♦ 7 Dear GP Re: Low priority procedure referral request We have received a referral from you which is considered to be a low priority procedure. The Primary Care Trust consider that the efficacy of certain procedures is such that they will not normally be funded without prior approval by the commissioner before referral. Where a provider receives a referral in relation to a low priority procedure, the provider shall not treat the patient, other than: where the patient’s condition is considered ‘urgent’ in the reasonable opinion of the provider; where the referral has previously been approved by the commissioner; or where the commissioner has previously referred a patient for review by the provider and, in the reasonable opinion of the provider, the procedure is deemed ‘clinically necessary’. We are therefore returning this referral to you as the patient’s GP, noting this is a low priority procedure not normally commissioned. Prior approval should only be sought where a patient clearly falls into a defined subgroup for which approval is warranted as set out in the Commissioner policies. If this is the case you should provide sufficient information to the Commissioner to enable this to be determined. Alternatively you may consider that a patient has exceptional clinical circumstances that can be proven with supporting information, and that warrant treatment outside of current commissioned treatment pathways. If this is the case you must provide further information to support the case being considered as an exception, including if appropriate, photographs. The PCT definition of exceptionality is as follows: The fact that a treatment is likely to be effective for a patient is not, in itself a basis for exceptional circumstances. In order for funding to be agreed, there must be some unusual or unique clinical factor about the patient that suggests that they are: o Significantly different to the general population of patients with the condition in question; o Likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. Please note that it is not appropriate to send requests for patients on cancer pathways or those requiring urgent surgery. In these circumstances the appropriate clinical pathway should be followed. Please refer to Introduction in Prior Approval Booklet for further guidance on exceptionality. Please ensure that your patient is made aware of why the referral has been returned from secondary care and that no further action will be taken unless prior approval is granted from the Primary Care Trust. Yours sincerely 51 INDIVIDUAL PATIENT REQUEST FORM 52 53 INDIVIDUAL TREATMENT REQUEST FORM Complete ALL relevant details. Please type or print CLEARLY. / Date form completed: 1. PATIENT DETAILS Last name: First name(s): Address: Gender: Male / Female Date of Birth: NHS Number: 2. DETAILS OF APPLYING CLINICIAN Trust Name: Address: Last name: First name(s): Telephone: Email: Are you the regular consultant? Who made this referral to you? 54 / 3. IF SPECIALIST, DETAILS OF PATIENT’S GP GP Name and Practice: GP Address: Is the GP aware of this request and had an opportunity for input? Yes / No Does the GP support this request? Yes/No/Do not know 4. DISEASE / CONDITION FOR WHICH TREATMENT IS REQUESTED * attach further information (including photos) if appropriate, a clinical report is useful, be specific In case of intervention for cancer: What is disease status? (eg at presentation, 1st/2nd or 3rd relapse) What is the WHO performance status? How advanced is the cancer? (stage) Describe any metastases: Has an opinion been sought from the MDT (with access to advice from a specialist in palliative care)? If Yes, give details. In case of intervention for non cancer: What is the patient’s clinical severity? (Where possible use standard scoring systems, Eg WHO, DAS scores, walk test, cardiac index etc). 5. TREATMENT REQUESTED Name of treatment: Is there an NHS Dorset or NHS Bournemouth & Poole policy governing access to this treatment: Yes / No (see attached list if unsure) If yes, please complete the following 55 Name of Policy: Explain how the patient meets the policy: [ Please go straight to section 8 ] If no, please complete the rest of the form If requesting a Medicine If requesting a Procedure / Technology Form and strength: Description of procedure and modality of delivery eg inpatient: Dosage to be used (include frequency): Dosage regimen: (where applicable) Duration of treatment / number of courses: Duration of treatment: Application supported by the requesting Trust through Drugs and Therapeutics Committee (or equivalent): Give name of Chair of relevant committee. Yes / No Name: Is the treatment NICE approved? Yes / No Is the treatment due for NICE approval within 12 months Yes / No Anticipated start date for treatment: / / The Individual Cases Panel meets monthly. If the case is more urgent than this, please state why: Are you aware of any other individual patients for whom you anticipate making a similar request? If yes, please indicate how many patients: Yes / No How many: Cost of treatment requested (include VAT if appropriate) to give cycle and annual cost: 56 6. ALTERNATIVE TREATMENT OPTIONS What would be the standard treatment at this stage? Provide a full list of treatments for this condition that have been tried or considered, including dates: Date: Intervention drug/surgery Reason for stopping/response achieved Please list or attach any other relevant treatments that the patient is currently taking/undergoing: 57 7. CLINICAL EVIDENCE Attach evidence that it is a safe and efficacious treatment: (e.g. full journal articles, not just references, conference proceedings or abstracts). Attached papers: Note that a higher degree of proof will be required for unregistered medications or registered medications for non-registered indications. Give details of National or Local Guidelines/Recommendations supporting the use of this treatment: Detail any cost/QALY information that is available for this treatment: Relevance of evidence to this patient: How will you monitor the effectiveness of this treatment? Ensure that patient’s current status against these measures has been provided in this application What are the stopping criteria for this patient if the patient is not benefiting as expected? What are the anticipated side-effects/toxicity of this treatment for this patient? Does the patient have any clinically exceptional circumstances relevant to this request? Please provide details. Is there any other relevant information that should be considered? (e.g. clinical factors / co-morbidities / relevant personal circumstances) What is the patient’s prognosis? With this treatment: Without this treatment: What is the expected response rate for the intervention requested? 58 8. PATIENT PROCESS Has the treatment been discussed with the patient? Yes / No / NA Has the patient been placed on the waiting list? Yes / No / NA Patients should not be put on waiting list unless approved for treatment. If relevant, has a TCI date been issued? Yes / No Do you have any conflicts of interest relating to the requested treatment? Yes / No If yes, please describe: Signature of Applying Clinician: Return completed form to: NHS Dorset NHS Bournemouth & Poole Individual Treatment Requests NHS Dorset Little Keep Gate Office Bridport Road Dorchester DT1 1AH Phone/Fax: 01305 361176 Email: [email protected] Or: [email protected] Individual Treatment Requests NHS Bournemouth and Poole Canford House Discovery Court Business Centre 551-553 Wallisdown Road Poole BH12 5AG Phone: 01202 541683 Fax: 01202 541905 Email: [email protected] 59 End file path: N:/Boscombe/bppctcomsdev/Liz Peek/Anna Doherty/PRIOR APPROVAL BOOKLET - PRIOR APPROVAL BOOKLET – SECOND VERSION – 14 MAY 2010 – updated 7 June 2010..doc 60