Download Procedure for making decisions in respect of: Individual Funding

Procedure for making decisions in respect of:
Individual Funding Requests
Version:
Version 12
Ratified by:
PCT Board
Date ratified:
18 January 2010
Name of originator/author:
Janet Wade
Name of responsible
committee/individual:
Janet Wade / Individual Funding
Request Panel (IFR)
Date issued:
January 2010
Review date:
February 2011
Target audience:
Practitioner Applying for IFR Funding
Contents Page
Policy & Procedure for Individual Funding Requests
1
Purpose
2
Scope
3
Accountability & Responsibilities
4
Summary
5
Background
6
Development of General Policies for Interventions
7
Individual Funding Requests
What is ‘exceptional’
8
Form of Individual Funding Requests
9
Triage
10 The Individual Funding Request Panel: Consideration of
requests
11 Consideration of Urgent Requests
12 Appeal
8
10
11
Policy & Procedure for Individual Funding Requests - Summary
13
Treatment Outside EEA
14
Treatment Application Forms
Treatment Request Form
Abdominoplasty Request Form
Breast Surgery Request Form
Breast Reduction Request Form
Gynaecomastia Request Form
15
15
19
20
21
22
Terms of Reference for the IFR Panel
23
Terms of Reference for the IFR Appeal Panel
25
Procedural Guidelines for IFR Appeals
27
Appeal Procedure for Appellant
29
Appeal Process – Patient Information
31
2
3
3
3
3
4
4
5
6
6
7
7
ROTHERHAM PRIMARY CARE TRUST
Policy and Procedure for Individual Funding Requests
1
Purpose
1.1 This document describes how Rotherham Primary Care Trust deals with requests for an
individual to receive a health care intervention that is not routinely funded by Rotherham
Primary Care Trust. Such requests are referred to in this document as Individual Funding
Requests.
1.2 For the purpose of this policy, and in common with the Secretary of State’s Directions to
Primary Care Trusts and NHS trusts concerning decisions about drugs and other treatments
2009, the term ‘health care intervention’ includes use of a medicine or medical device,
diagnostic technique, surgical procedure and other therapeutic intervention.
2
Scope
2.1 This policy applies to all employees of Rotherham Primary Care Trust, any staff who are
seconded to Rotherham Primary Care Trust, contract and agency staff and any other
individual working on Rotherham Primary Care Trust premises.
2.2 The policy should be read in conjunction with other relevant procedures and policies for
Rotherham Primary Care Trust.
3
Accountability and Responsibilities
3.1 The lead Director with overall responsibility for this policy is the Director of Public Health.
3.2 Responsibility for processing, considering and determining Individual Funding Requests on
behalf of Rotherham Primary Care Trust is delegated to those involved in the processes set
out in this policy.
3.3 All Rotherham Primary Care Trust staff are bound by the terms of this policy.
3.4 This document has been developed in collaboration with NHS Yorkshire and the Humber
and the Yorkshire and the Humber Specialised Commissioning Group as an executive
committee of the 14 PCTs in the region.
3
4
Summary
The overall process for dealing with Individual Funding Requests has three key stages:
Triage
Individual Funding Request (IFR) Panel
Appeals Panel
All of these stages are of significant importance and require appropriate resourcing in terms
of manpower and skills. An easy reference summary of the key features of the process is on
page 11
Consideration of urgent requests is set out in section 11 below
5
Background
5.1 This policy has been developed in response to the legal duties set out in the Secretary of
State’s Directions to PCTs and Trusts, the NHS Constitution, and a range of guidance as set
out below:
5.1.1
The NHS Constitution (January 2009); two rights relate specifically to the availability
of medicines and other treatments:
You have the right to drugs and treatments that have been recommended by NICE
for use in the NHS, if your doctor/registered health practitioner says they are
clinically appropriate for you.
You have the right to expect local decisions on funding of other drugs and treatments
to be made rationally following a proper consideration of the evidence. If the local
NHS decides not to fund a drug or treatment you and your doctor/registered health
practitioner feel would be right for you, they will explain that decision to you.
5.1.2
Directions to Primary Care Trusts and NHS Trusts concerning decisions about drugs
and other treatment 2009 (Secretary of State,12 March 2009), which set out primary
care responsibilities on funding and commissioning health care interventions, and the
duty to give reasons for decisions.
5.1.3
The World Class Commissioning Framework.
5.1.4
Guiding principles for processes supporting local decision-making about medicines
and a Handbook of Good Practice Guidance (Department of Health/National
Prescribing Centre, February 2009).
5.1.5
Guidance on NHS patients who wish to pay for additional private care (Department
of Health, March 2009).
4
6
Development of general policies for interventions
6.1 Rotherham Primary Care Trust has a statutory responsibility to commission care, including
medicines and other treatments, for its population within available resources.
6.2 Each year, Rotherham Primary Care Trust plans investment in health care interventions and
services as part of its operating plan development process to meet the needs of its local
population. Decisions on funding are usually made in collaboration with provider Trusts and
other stakeholders, and are taken in the context of the Rotherham Primary Care Trust’s
available resources to ensure that care is fairly allocated to all patients and, where
appropriate, measured against Rotherham Primary Care Trust’s other service development
priorities, NICE guidance and national priorities.
6.3 When planning its investments, Rotherham Primary Care Trust works with provider partners
to identify, as far as possible, those new interventions that are likely to have a significant
clinical impact and require funding in the coming years. This is often referred to as horizon
scanning.
6.4 Most health care interventions are commissioned as part of Service Level Agreements with
provider partners. However, it is likely that, during the year, there will be requests for
interventions not covered by Rotherham Primary Care Trust commissioning policies.
Rotherham Primary Care Trust, therefore, needs to be able to make decisions about these
requests that are fair and consistent.
6.5 Rotherham Primary Care Trust will use a standard Individual Funding Request submission
form to receive such requests and will triage all such requests to identify whether a funding
request submitted on behalf of an individual would apply to a population of patients. Where
that is the case, the request will trigger the development of a new policy for that intervention
and indication (called a general policy) or modification of an existing general policy. These
requests will not be generally considered by the Individual Funding Request Panel.
6.6 Arrangements for the development and revision of general policies by Rotherham Primary
Care Trust for health care interventions are available from Rotherham Primary Care Trust.
6.7 Rotherham Primary Care Trust will make its general policies available on request or at
http://www.rotherhampct.nhs.uk/policiesprocedures
5
7
Individual funding requests
7.1 An Individual Funding Request is appropriate where either the following applies:
7.1.1
Rotherham Primary Care Trust has a general policy not to fund a health care
intervention for the specified indication but a doctor considers his/her patient to be
‘exceptional’ to that policy, OR
7.1.2
Rotherham Primary Care Trust has no policy in place for the requested health care
intervention and indication and the clinical circumstance is so rare that it is unlikely
that any other patients will require the intervention.
7.2 In responding to an Individual Funding Request, Rotherham Primary Care Trust accepts no
clinical responsibility for the health care intervention or its use, or for the consequences of
not using the intervention.
7.3 Decisions about which health care interventions are to be requested are the responsibility of
the treating doctor and the provider organisation.
7.4 In instances where there is disagreement between clinicians or between the patient and their
doctor as to which intervention is to be requested or the manner in which it is to be
administered, Rotherham Primary Care Trust will take no part in these discussions other
than to provide current commissioning policies. It is the duty of the referring provider’s
organisation to obtain appropriate arbitration in instances of disagreement between clinicians
or between patients and clinicians.
What is ‘exceptional’?
7.5 Exceptionality should be considered in the context of the Rotherham Primary Care Trust
general policy for a health care intervention and specified indication.
7.6 In general, Rotherham Primary Care Trust must justify the grounds upon which it chooses to
fund a health care intervention for a patient when that intervention is unavailable to others
with the condition.
7.7 A patient may be considered exceptional to the general policy if both the following apply:
7.7.1
He/she is different to the general population of patients who would normally be
refused the health care intervention AND
7.7.2
There are good grounds to believe the patient is likely to gain significantly more
benefit from the intervention than might be expected for the average patient with that
particular condition.
7.8 When considering Individual Funding Requests, Rotherham Primary Care Trust will use the same
ethical framework and guidelines for decision-making that underpin its general policies for health
care interventions. Where social, demographic or employment circumstances are not considered
relevant to population-based decisions, these factors will not be considered relevant to Individual
Funding Requests.
6
7.9 Where a patient has already been established on a health care intervention, for example as part
of a clinical trial or following payment for additional private care, this will be considered to neither
advantage nor disadvantage the patient when making an Individual Funding Request. The
patient's response to an established or previously provided intervention will not be considered to
be an exceptional factor.
8
Form of Individual Funding Requests
8.1 All Individual Funding Requests must be submitted in writing to the Chair of the IFR Panel.
8.2 Individual Funding Requests will be accepted from doctors and other registered health
practitioners
8.3 When making an Individual Funding Request the treating doctor/registered health
practitioner must complete the appropriate standard IFR submission form and submit it to
the Chair of the IFR Panel, copying it to the patient’s GP if requested. The information
requested in the standard form is the minimum data required for the IFR Panel to consider
the request.
8.4 Where an Individual Funding Request is received from a clinician otherwise than on the
standard IFR form, the standard response by the PCT will be to write back to the clinician
enclosing a copy of the form and requesting that this be completed and returned as soon as
possible, otherwise the request cannot be processed. The only exception to this standard
response will be where, in the opinion of the IFR Panel Member triaging the request (see
below), the information already provided by the clinician covers all of the minimum data
required by the standard form.
8.5 Where an application is made on the standard form but does not contain all of the minimum
data required, the IFR Panel will not consider the request and instead the IFR Panel
Member triaging the request will return the application to the clinician who submitted it with
a request for the outstanding information to be provided.
8.6 Should a patient approach the PCT direct with an Individual Funding Request, they will
either be advised to approach their own GP or supported to find an alternative suitable
clinical advisor. Once a GP/clinical advisor has been identified NHS Rotherham will forward
the appropriate Individual Funding Request Panel submission form to that professional to be
completed and returned by them. Additional support may also be offered to the patient via
the Patient Advice and Liaison Service (PALS) or independent advocacy services if they
wish.
9
Triage
9.1 Following receipt of an Individual Funding Request at the PCT, a member of the IFR Panel
will triage the request. Triage will take place within 28 days of the request being received at
the PCT.
9.2 There are five possible outcomes to triage:
7
The requested health care intervention is funded by the PCT as part of a general policy.
If this is the case, the treating doctor/registered health practitioner who made the
request will be advised by Rotherham PCT in writing of the general policy and no further
action will be taken by the IFR Panel or the PCT.
The health care intervention is not funded by the PCT as part of a general policy but the
treating doctor/registered health practitioner has identified in the request documentation
potential reasons why the patient should be considered an exceptional case justifying
funding and on triage it is considered that all of the information required to allow proper
consideration by the IFR Panel has been provided. If so, the case will be considered at
the next available IFR Panel (see paragraph 10 below).
The health care intervention is not funded as part of a general policy and the treating
doctor/registered health practitioner making the request does not identify any reasons
why the patient should be considered an exceptional case justifying funding. In such a
case the treating doctor/registered health practitioner will be advised of the general
policy and no further action will be taken by the IFR Panel or the PCT.
The request has not been made on the standard IFR form and/or does not contain the
minimum data required. In such a case the request will be returned to the treating
doctor/registered health practitioner with a request for the further information required.
No further action will be taken by the IFR Panel or the PCT until the further information
has been received.
The request documentation contains all of the minimum data required but the Panel
Member triaging the request nonetheless considers that further information will be
required in order for the IFR Panel to give the request proper consideration. In such a
case appropriate enquiries will be made by an IFR Panel member to obtain the further
information in question. No further action will be taken by the IFR Panel or the PCT until
the further information has been received.
10 The Individual Funding Request Panel: consideration of requests
10.1 Individual Funding Requests will be forwarded to the IFR Panel for consideration in the
circumstances set out at paragraph 9.2 above. The IFR Panel will consider any given request at
its next scheduled meeting following receipt of all necessary information required to consider the
request.
10.2 The Terms of Reference of the IFR Panel are set out on page 21 of this Policy. Panel
meetings take place every two weeks. Consequently it is expected that cases will be considered
by the IFR Panel within 14 days of receipt of the information necessary to consider the request.
10.3 In light of this expectation Rotherham PCT will not ordinarily correspond with those making an
Individual Funding Request with regard to timescales. However in complex cases or cases
where further information is requested by the PCT such that the request cannot be considered
within 14 days, the PCT will keep the patient and their treating clinician informed at all times of
the likely timescales for the process.
8
10.4 The PCT will aim to ensure that all Individual Funding Requests are considered by the
IFR panel within a maximum of 56 days from first notification of the request to the PCT.
10.5 At any time following submission of the Individual Funding Request and before the relevant
IFR Panel meeting the patient and/or their treating clinician may submit to the Panel any further
information that they consider relevant to the request.
10.6 The patient and/or their treating clinician may not attend the Panel meeting unless specifically
invited by the Panel.
10.7
The Panel will take the following into consideration when making decisions:
Policy Guidance: NICE, or any local or national guidance from the UK NHS including
Yorkshire and Humber Specialist Commissioning Group Rotherham PCT Board
approved policy
Good quality evidence of effectiveness (hierarchy of evidence1)
Place in therapy relative to available health care interventions
Affordability and value for money
Evidence of exceptionality (see 7.5 - 7.9 above for guidance)
Legal considerations, as set out in the NHS Confederation document ‘Priority Setting:
Legal Considerations’ (2008)
Views of patient and clinicians.
10.8 In cases where there is no relevant local or national guidance, it is up to the requesting
clinician or patient to provide all the appropriate evidence to the Panel with the original request.
10.9 The treating doctor/ registered health practitioner and the patient may have access to the
clinical information submitted to the IFR panel but may not attend meetings of the Panel unless
specifically invited.
10.10 Where necessary or appropriate, the Panel will seek legal advice to ensure its decisions are
fair and equitable.
10.11 The Panel will always seek to make a unanimous decision. Where this is not possible, the
Panel will take a majority decision with the Chair having the casting vote.
10.12 Potential outcomes of the Panel's deliberations are as follows:
On the available evidence the patient cannot be considered an exceptional case and so the
request is declined;
On the available evidence the patient should be considered an exceptional case and so
funding is approved as an exception to the general policy;
During the Panel's deliberations it is identified that further information or specialist advice is
required in order for a decision on the request to be made and the decision must be
deferred until that information/advice has been received.
1
a Strong evidence from at least one systematic review of multiple well designed randomised controlled trials
b Strong evidence from at least one properly designed randomised controlled trial of appropriate size.
c Evidence from well-designed trials such as non-randomised trials, cohort studies, time-series or matched case controlled
studies.
d Evidence from well-designed non-experimental studies from more than one centre or research group.
e Opinions of respected authorities, base on clinical evidence, descriptive studies or reports of expert committees.
9
The patient has a rare condition and the treatment requested is supported
The patient has a rare condition but treatment requested is not supported.
10.13 In a case where the Panel identifies that additional information will be required, this
information will be requested by the PCT as soon as possible after the Panel meeting and the
matter referred back to the IFR panel once that information has been received.
10.14 Decisions will be documented by the Panel at its meeting and communicated directly to the
referring clinician and the patient giving a written statement of the reasons for the decision. This
will be done within 7 working days of a decision being reached.
11 Consideration of urgent requests
11.1 Occasionally clinical circumstances may require urgent use of a health care intervention
that is not funded by the PCT as part of a general policy and will require an individual
funding decision. An Individual Funding Request will be considered urgent by the PCT in
circumstances where the decision on funding is required before the next scheduled meeting
of the IFR Panel is due to take place because treatment cannot safely be postponed until
after that IFR Panel meeting. The PCT will endeavour to respond to such requests as
quickly as possible but this should not compromise the quality and validity of the decision
making process.
11.2 The process for making and considering urgent Individual Funding Requests is as
follows:
11.3 All applications for treatment or funding that are marked urgent will be acknowledged by
telephone, fax or e-mail on the day of receipt wherever possible, or if not the next working
day, by the Chair/Panel member of the Individual Funding Request Panel who will triage the
request.
11.4 Wherever possible the standard IFR form should be used for an urgent request as for a
standard request. However if the minimum data set is submitted (8.4) this will be
considered.
11.5 If the timescale within which a response is required to meet the patient’s clinical need is
not evident from the request documentation, telephone contact will be made with the
applicant to confirm this.
11.6 Should additional information be required requests will be made by telephone contact
direct with the requesting clinician.
11.7 Urgent decisions will be made by two clinical members of the Individual Funding
Request Panel, preferably by face to face meeting, however telephone or e-mail discussion
is acceptable. Where those two panel members disagree a third panel member will be
called to consider the request and the matter will be determined by a majority amongst
those three panel members.
10
11.8 The Chair/Individual Funding Request Panel member will notify the referring clinician of
the decision, on the day that it is made, by telephone followed by written confirmation.
11.9
The decision reached will be noted at the next IFR Panel meeting.
11.10 At all times the provider partner which is proposing treatment is able to provide a health
care intervention pending a decision on funding from Rotherham Primary Care Trust.
Rotherham Primary Care Trust accepts no responsibility for the clinical consequences of
any delay in responding to an urgent Individual Funding Request, nor does it accept any
financial responsibility in circumstances where the treatment is provided before the IFR
Panel has reached its decision on funding.
12 Appeal
12.1 Appeals against decisions of the IFR Panel will be heard by the Rotherham PCT IFR
Appeals Panel. The Appeals Panel's Terms of Reference are included on page 25 of this
Policy.
12.2 IFR Appeals can be initiated by the patient or the referring clinician by contacting the
PCT in writing. All individuals who wish to appeal will receive information about the
appeals process. IFR Appeals must be initiated within three months of the Panel decision.
12.3 An appeal request will be acknowledged within 7 working days. The IFR Appeals Panel
will meet as soon as practicable. Unless further information is awaited this should be no
longer than three months after receipt of the appeal request.
12.4 The IFR Appeals Panel provides a procedural review of the IFR Panel decision. The IFR
Appeals Panel has access to all the relevant documentation regarding the request but does
not, in general, consider new evidence.
12.5
The review will include:
Was due process followed? Did the PCT follow its own policies and procedures.
Did the IFR Panel take in to account all of the relevant information available at the time?
Was the decision reasonable in light of all the evidence.
12.6 Generally the case will be considered by the Appeals Panel on paper without either side
being present. However, if, in exceptional circumstances, the Appeals Panel believes that it
would benefit that Panel to have one side present at the hearing, the other side will also be
invited to attend.
12.7
Where a patient does attend, procedural guidelines will be followed (see page 27).
12.8 The patient and the treating doctor/registered health practitioner will be sent a set of
papers submitted to the Appeals Panel by Rotherham Primary Care Trust.
12.9 The IFR Appeals Panel may decide to uphold the original decision, to reverse it, or to
ask the IFR Panel to consider the request again.
12.10 The Chair of the IFR Appeals Panel, or designated officer, will inform the patient, the
treating doctor/registered health practitioner, the PCT and, if requested, the patients’ GP, of
11
the decision of the Appeals Panel. The decision will be communicated in writing within 7
working days of the Appeals Panel.
12.11 The decisions of the Appeals Panel are final.
12.12 If the IFR Appeals Panel upholds the original decision not to fund an intervention, the
patient may choose to complain about the decision within the NHS complaints procedure.
12
POLICY & PROCEDURE FOR INDIVIDUAL FUNDING REQUESTS SUMMARY
The overall process for dealing with individual funding requests has three key stages; all of
which are of significant importance and require appropriate resourcing. These three key
stages are summarised below:-
Triage
Receives and acknowledges individual
funding requests from providers
Assesses requests against existing
policies and for completeness
Requests for interventions where there
is a policy to not fund are returned to
the provider unless explicit evidence of
exceptionality is provided
New treatments requiring policy
development are referred for
consideration as part of the PCT
planning process
Further information is requested from
the provider, if necessary, for requests
to be referred to the IFR panel
Provider and patient are informed of
timescales for PCT decision
Individual funding
request (IFR) panel
Receives individual funding requests
from Triage
Receives appraisal of the requested
intervention from PCT clinical advisors
Funding decision made and
communicated to the provider and the
patient
Receives case for appeal on paper
Provides procedural review
Decision of the Panel
communicated to the PCT, the
patient, and the provider
Appeals panel
13
TREATMENT OUTSIDE THE EUROPEAN ECONOMIC AREA (EEA)
Requests for health care interventions outside the EEA will be considered in line with the
Department of Health Patients Information Circular (14 March 2007), which states that:
‘Patients do not have a right to have treatment outside the European Economic
Area (EEA) paid for by their local PCT. Individuals requesting treatment outside
the EEA should be aware that PCT’s are advised to consider the following criteria
before approving treatment outside the EEA’
The condition is of a serious nature.
Suitable treatment is not available within the UK or the EEA.
The treatment abroad is well established, not merely experimental.
There is a probability of significant benefit to the patient.
Clinicians will need to demonstrate how their patient meets these criteria as part of the
individual funding request.
14
Treatment Request Form
Section A – patient and referring clinician details
Surname
Patient details
Referring clinician details
Applicant Name
Forename(s)
Contact / Email
Address and Post Code
Practice Address and Post Code
Date of Birth
GP Name & Contact Details, if not the
referrer
NHS No.
Gender
Entitled to NHS treatment?
Yes / No
Is the Patient aware that this approval
request has been made to the PCT?
Date Received (PCT Use)
YES / NO
Has the patient received a copy of all the
information forwarded to the PCT?
Patient Initials (PCT Use)
YES/NO
Section B – please complete for ALL requests
Patient Diagnosis / Issue
Specify:
Provider
Procedure
Course of treatment
Trial
Other
Details of intervention requested:
15
What are the exceptional circumstances?
What are likely consequences for patient if this application is not
approved?
What is the evidence-base for this intervention?
Definition of exceptionality:
He/she is different to
the general population
of patients who would
normally be refused the
health care intervention
AND
there are good grounds
to believe the patient is
likely to gain
significantly more
benefit from the
intervention than might
be expected for the
average patient with
that particular condition.
• Future health
• Potential use of healthcare
services
• Financial cost to patient
Clinical effectiveness, costeffectiveness;
Assessments / publications
by advisory bodies
(please attach)
Has patient been seen by a local consultant, if appropriate?
If not, why are local services
not sufficient?
Please indicate cost of proposed treatment:
Where possible
Section C – Please complete for requests for drug treatments
Further details of intervention (for which approval is requested)
Dose and frequency
Planned duration
Of intervention
Exit strategy / stopping
criteria
(e.g. disease
progression, poor
response, adverse
events)
16
Route of administration
Anticipated cost (inc
VAT) – seek advice
from pharmacy
Is requested
intervention part of a
clinical trial?
Delete as appropriate: No / Yes
If Yes, give details (e.g. name of trial, is it an MRC/National
trial?)
What would be the standard intervention at this stage (including cost)?
What are the exceptional circumstances that make the standard intervention
inappropriate for this patient?
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:
In case of intervention for noncancer:
What is the patient’s clinical severity? (Where possible
use standard scoring systems e.g. WHO, DAS scores,
walk test, cardiac index etc.)
17
Summary of previous
intervention(s) this patient has
received for the condition.
Dates
Intervention (e.g.
drug / surgery)
* e.g. Course completed / No
or poor response / Disease
progression / Adverse effects
or poorly tolerated
Anticipated start date
Processing requests can take
up to 2 weeks (from the date
received by the PCT). If the
case is more urgent than this,
please state why:
PLEASE CONTINUE ON A SEPARATE SHEET IF NECESSARY
Please send
completed form and
accompanying
documents to:
Mrs Janet Wade
Senior Nurse Case Manager
NHS Rotherham
Oak House
Rotherham
S66 1YY
18
Reason for
stopping* /
Response
achieved
ABDOMINOPLASTY REQUEST FORM
PATIENT IDENTIFICATION DETAILS
PATIENT’S NAME
NHS NO:
DATE OF BIRTH
ADDRESS
REFERRING GP
In your clinical opinion is the patient currently experiencing severe difficulties with daily living? ie
ambulatory restrictions YES / NO
If YES please give details:
Please specify any patient weight loss that has contributed to the perceived requirement for
abdominoplasty:
Initial Weight (kg)
Date (mm/yy)
Current Weight (kg)
Date (mm/yy)
Total Weight Loss to Date
Height
Current BMI
Length of time current weight loss has been stable
Does the patient suffer from any other conditions related to the requirement for abdominoplasty
(eg persistent intertrigo)?
Details:
GP Signature ………………………………………..
Date …………………………………
19
BREAST SURGERY (AUGMENTATION/ASYMMETRY)
PATIENT IDENTIFICATION DETAILS
PATIENT’S NAME
NHS NO:
DATE OF BIRTH
ADDRESS
REFERRING GP
ADDITIONAL INFORMATION
WEIGHT
HEIGHT
CHEST SIZE
CUP SIZE – LEFT
In your opinion does the patient have amastia of the breasts?
CUP SIZE - RIGHT
YES / NO
Please provide supporting information to demonstrate the exceptionality of this case and
which you consider is relevant to your patient’s request for breast augmentation.
NB Psychological assessment is not routinely requested or taken into account when NHS
Rotherham considers requests for breast augmentation.
GP Signature …………………………………………
Date ……………………………………………………
20
BREAST REDUCTION REQUEST FORM
PATIENT IDENTICATION DETAILS
PATIENTS NAME
NHS NO:
DATE OF BIRTH
ADDRESS
REFERRING GP
ADDITIONAL INFORMATION
WEIGHT
HEIGHT
BMI MEASUREMENT
CHEST SIZE
CUP SIZE
Do you consider your patient to be overweight?
YES / NO
Do you consider your patient’s breast size proportionate to her body?
YES / NO
Does the patient complain of any functional problems, which can be attributed to the breast
hypertrophy?
YES / NO
If YES, have other investigations been undertaken which consider other pathological causes of
functional problems?
YES / NO
If YES please state what these investigations were and their outcome:
Any other information which is relevant to your patient’s request for breast reduction
NB Psychological assessment is not routinely requested or taken into account when NHS
Rotherham considers requests for breast reduction.
.
GP Signature …………………………………………………………..
Date ……………………………………………………………………..
21
Correction of Gynaecomastia Request Form
PATIENT IDENTIFICATION DETAILS
PATIENT’S NAME:
NHS NO:
DATE OF BIRTH:
ADDRESS:
REFERRING GP:
ADDITIONAL INFORMATION
WEIGHT:
HEIGHT:
BMI MEASUREMENT:
Do you consider your patient to be overweight?
CHEST SIZE:
YES/NO
Can you confirm that your patient has not taken any performance enhancing drugs within the last
12 months?
YES/NO
In accordance with the policy criteria and in your view, would surgery remove more than 100g of
glandular tissue?
YES/NO
Have investigations been undertaken which consider other pathological causes gynaecomastia?
YES/NO
If YES please state what these investigations were and their outcome:
Any other information which is relevant to your patient’s request towards surgery for gynaecomastia
GP Signature …………………………………………
22
Date ……………………………….
TERMS OF REFERENCE OF THE INDIVIDUAL FUNDING
REQUEST PANEL
Contact Details:
Lead Director/
Clinician:
Dr John Radford
Lead Officer:
Janet Wade
Title:
Director of Public
Health
Title:
Senior Nurse Case
Manager
Purpose:
To consider individual funding requests for approval
Responsibilities:
To make decisions on Individual Funding requests
To ensure a consistent approach to decision making on these requests
To maintain a clearly documented record of the decisions made
To communicate decisions in a timely manner
To note outcomes of cases heard at the Appeals Board
To provide an annual report to the PCT Professional Executive and Board.
Chair:
Senior Nurse Case Manager
Composition of group:
Clinical
Senior Nurse Case Manager (Public Health) (Chair)
2 (designated clinicians), appointed by Rotherham PCT
Public health consultant
Head of Medicines Management
Continuing Care Nurse
Non Clinical
Head of Secondary Care and Local Authority contracting
Deputy Director of Finance
Programme manager for Planned Care
23
In Attendance:
Other members of staff may be invited to attend the Panel meeting in an advisory
(non voting) capacity as necessary to give specialist advice.
Deputising:
Members can nominate deputies to attend a specific meeting (identified by title
within membership)
Quorum:
Quoracy of the Panel is four, two of whom must be clinicians.
Accountability:
Director of Public Health
Frequency of meetings:
Every two weeks
Order of business:
Normal
Agenda deadlines:
Thursday prior to Panel meeting
Minutes:
To be circulated to all Panel members and stored confidentially within the Public Health
Directorate as a hard copy and electronically which is pass word protected.
Administration:
Secretary to the Chair of the IFR Panel.
Attendance:
Members are expected to attend 75% of meetings on an annual rolling basis.
Review Date:
September 2011
24
INDIVIDUAL FUNDING REQUEST APPEAL PANEL
TERMS OF REFERENCE
Contact Details:
Lead Director/
Clinician:
Dr John Radford
Lead Officer:
Janet Wade
Title:
Director of Public
Health
Title:
Senior Nurse
Manager
Purpose:
To provide a procedural review of the Individual Funding Request Panel decision.
In circumstances where there is no previous policy statement, the decision to decline the
request was arrived at with reference to available evidence.
Responsibilities:
To consider and review the IFR Panel’s decision in relation to the funding of the
individual’s treatment by reference to fair and appropriate application of the
process.
Decisions will be made by a majority of the members, (the advisor having no
voting rights).
The clinician/individual will be entitled to make representations, in writing to the
Appeals Panel.
The Appeals Board will have the right to request the individual’s relevant clinical
records and comments from the treating Clinician(s) with the patient’s consent
and will obtain any specialist advice it deems appropriate to assist it in reaching
its decision.
The individual, treating clinician, IFR Panel and, if requested, GP will be
informed in writing within 7 days of the Appeal as to the result of the Appeals
Panel decision and its reasons.
In exceptional circumstances the patient and representatives from the IFR Panel
may be invited to attend. In such cases the procedural guidelines will be followed
(page 25).
Chair:
A Non Executive member of the PCT Board.
25
Composition of group:
Two Non-Executive PCT Board Members and a member of the Professional
Executive.
Appeal Panel members will not be members of the Priorities Panel and will have
no interest or input into the decision making process in relation to the original
Individual Funding Request
In Attendance:
A medically qualified advisor with at least 10 years post qualification experience
(non-voting)
Deputising:
Not relevant
Quorum:
All
Accountability:
NHS Rotherham Board
Frequency of meetings:
As required
Order of business:
This may vary depending on whether the patient and PCT representative have been
invited to attend.
Agenda deadlines:
All papers to be collated ready to be forwarded to Appeal Panel members 10 days prior
to Panel meeting.
Minutes:
To be circulated to all Appeal Panel members, solicitor, medical advisor, patient and
PCT representative if attended. These will be stored confidentially within the Public
Health Directorate both electronic and hard copy.
Administration:
P A to Director of Public Health.
Attendance:
Not relevant this membership fluid.
Review Date:
September 2011
26
PROCEDURAL GUIDELINES FOR APPEALS
Appeal Procedure
Appeal Panel meet half an hour prior to appellant. This is an opportunity to
discuss procedure
Identify any queries with information provided.
At this time PCT representatives are available if required for clarification of any of the
information.
Introductions
Invite appellant/s into room
Introduce to Appeal Panel
Invite PCT representatives and introduce to Appellant and Appeal Panel.
Explanation that Appeal Panel are independent and have not been part of the
decision making process, that they are Non Executive members of the PCT
Board and Professional Executive. The Solicitor is there as a clerk to the PCT
and to ensure process is correct. Medical Adviser does not have a vote and is
there purely to assist/explain medical/clinical issues raised. Minute taker.
Purpose of the Appeal Panel
Brief introduction by Chair of reason for the Appeal. (it is not the role of the
Appeal Panel to make a decision in place of the IFR Panel ) but to ensure that
the PCT has followed the process correctly and made a reasonable judgement.
Possible outcomes
The outcome of the Appeal Panel’s decision can be:
Uphold the IFR Panel’s decision
Refer the request back to the IFR Panel for reconsideration.
In exceptional cases the Appeal Panel may award approval without referring the
request back to the IFR Panel.
Process
Explain that the appeal will be minuted and taped to assist with accuracy and will be
wiped once minutes are agreed. The tape will be stopped once the appellant leaves the
room.
Confirm all have copies of the relevant papers. Have any additional papers been
brought on the day.
Appellant to present case to Appeal Panel
Appeal Panel members/PCT ask questions via Chair
PCT case presented
Appeal Panel members/appellant ask questions via Chair
PCT representatives and Appellant summarise.
27
PCT representatives and Appellant asked to leave
Appeal Panel deliberate.
Confirm all understand and agree to process.
Next steps
Appeal Panel decision will be communicated to Appellant by letter within 7
working days.
28
Appeal procedure - Appellant
Introductions
You will be invited into the room.
You will be introduced to the Appeal Panel.
The PCT representatives will be invited into the room and introduced to yourself
and the Panel.
The Appeals Panel are independent and have not been part of the decision
making process. They are Non Executive members of the PCT Board and
Professional Executive.
The Solicitor is there as a clerk to the PCT and to ensure process is correct.
The Medical Adviser does not have a vote and is there purely to assist/explain
medical/clinical issues raised.
There will be a minute taker present.
Purpose of the Appeal Panel
There will be a brief introduction by the Chair of the reason for the Appeal. It is
not the role of the panel to make a decision in place of the IFR Panel, but to
ensure that the PCT has followed the process correctly and made a reasonable
judgement.
Possible outcomes of the Appeal
Uphold the IFR Panel’s decision
Refer the request back to the IFR Panel for reconsideration.
In exceptional cases the Appeal Panel may award approval without referring the
request back to the IFR Panel
.
The decision is binding on the PCT.
Process
The appeal will be minuted and taped to assist with accuracy once the minutes
are agreed. The tape will be stopped once you and the PCT representatives
leave the room.
The Chair will confirm that all have copies of the relevant papers and ask if any
additional papers have been brought on the day.
You will be asked to present your case to the Appeal Panel.
The Appeal Panel members and PCT representatives will ask questions via the
Chair
The PCT representatives will then present the PCT’s case.
You and the Appeal Panel members will ask questions via the Chair.
You will be asked to summarise your case.
The PCT representatives will then be asked to summarise their case.
You and the PCT representatives will be asked to leave the room.
The Appeal Panel will deliberate.
The Chair will confirm that everyone understands and agrees to the process.
29
Next steps
The Appeal Panel decision will be communicated to you by letter within 7 working
days.
30
The Appeals Procedure, Patient Information
THE APPEALS PROCESS (following a negative IFR Panel decision)
Processes can be challenged on the grounds of:
Was due process followed? Did the PCT follow its own policies and procedures?
Did the IFR Panel take in to account all of the relevant information available at the
time?
Was the decision reasonable and in line with the evidence?
It is not the role of the Appeals Panel to re-write policy or to make a decision in place of
the IFR Panel but to ensure that Rotherham PCT has followed the process correctly and
fairly.
The Appeals Panel will meet as soon as practicable and within 3 months of notice of the
appeal unless further information is awaited.
POSSIBLE APPEAL OUTCOMES
The outcome of the Appeal Panel’s decision can be:
Uphold the IFR Panel’s decision
Refer the request back to the IFR Panel for reconsideration.
In exceptional cases the Appeal Panel may award approval without referring the
request back to the IFR Panel.
The Rotherham Primary Care Trust Appeals Panel will consist of Two Non Executive
PCT Board Members and one member of the PCT Professional Executive assisted by a
medically qualified advisor with a least 10 years post qualification experience (nonvoting). Decisions will be made by a majority of the Appeals Panel members. The
Appeals Panel role is to ensure that the Individual Funding Requests Policy has been
applied correctly. In circumstances where there is no previous policy statement, the
decision to decline the request was arrived at with reference to available evidence and
the patient’s particular circumstances.
For the purpose of an appeal individuals will be made aware of all the evidence used in
reaching that decision and any evidence to be considered at the appeal and be
provided with copies if requested.
Individuals will have the opportunity to make representation in writing to the board and
in exceptional circumstances in person. If patient is invited to attend they may
choose to be accompanied by a friend, relative or representative.*
The individual will be informed in writing as to the result of the Appeals Panel decision
and its reasons.
31
The individual patients’ requesting clinician, IFR Panel and, if requested, GP will be
informed in writing as to the result of the Appeals Panel decision and its reasons within
7 working days.
* ICAS (Independent Complaints Advocacy Service) 0845 1203734
* PALS (Patient Advice and Liaison Services) 01709 302108
32