Download (Attachment: 3)DORSET HEALTH AUTHORITY

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
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N:/Boscombe/bppctcomsdev/Liz Peek/Anna Doherty/PRIOR APPROVAL BOOKLET - PRIOR APPROVAL BOOKLET – SECOND VERSION – 14
MAY 2010 – updated 7 June 2010..doc
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