Download south central strategic health authority cancer drug fund

Policy and Procedure for
Individual Funding Requests (IFRs)
Guidance for clinical practice
Activity Log for Joint Referral Panel
Operational Details for Previous panels can be found at Appendix 1
Date
Approved By
Activity
Amended by
November
2010
NHS Southampton
Clinical Leadership
Board
12 January
2011
For NHS Hampshire
PAC (not convened)
Changes to Policy title to ‘Individual Funding
Chris Ashdown
Requests’ and first joint policy covering NHS
Hampshire and NHS Southampton City with
joint Panel structure.
Housekeeping of document to take account of
Chris Ashdown
changes to application form which will include
reference to potential service development
Re-arrangement of exclusions list to separate
between:
i. Core list of interventions that are
“not normally funded”.
ii. Criteria-based commissioning
for procedures of limited clinical
value (PLCV) using the Prior
Approval Tool
iii. Volume thresholds/ quota-based
commissioning
15/02/11
NHS Hampshire
PAC / Management
Committee
Finalising of ‘new’ procedures of limited
clinical value, addition of procedure codes and
ordering into ‘don’t dos’ and ‘may dos’.
Inclusion of revised application form and
guidance notes for use in primary care only.
(Current application still to be used in
secondary care)
Chris Ashdown/
Cathy Price/
Marie-Claire
Lobo
Page 1 of 51
CONTENTS
1
INTRODUCTION .................................................................................................................................. 3
2
REFERRALS TO BE DEALT WITH UNDER THE POLICY - EXCEPTIONALITY................................ 3
3
POLICY SCOPE ................................................................................................................................... 3
5
DECISION-MAKING FRAMEWORK ..................................................................................................... 5
6
PROCESS ............................................................................................................................................ 6
7
HAMPSHIRE AND SOUTHAMPTON CITY JOINT REFERRAL PANEL ............................................... 8
8
PCT APPEALS PANELS ...................................................................................................................... 9
9
PCT APPEAL BODY ............................................................................................................................. 9
10
SERVICE DEVELOPMENTS .............................................................................................................. 10
11
IMPLEMENTATION OF NICE GUIDANCE ......................................................................................... 10
12
MANAGING THE ENTRY OF NEW DRUGS ...................................................................................... 10
Appendices
1
PRIOR APPROVALS .......................................................................................................................... 13
2
EXCLUDED PROCEDURES
3:
SOUTH CENTRAL ETHICAL FRAMEWORK ..................................................................................... 33
4
INDIVIDUAL FUNDING REQUEST (IFR) APPLICATION FORM (Secondary care) ........................... 36
5
INDIVIDUAL FUNDING REQUEST (IFR) APPLICATION FORM (Primary Care) ............................... 41
6
SOUTH CENTRAL STRATEGIC HEALTH AUTHORITY CANCER DRUG FUND .............................. 47
7
COSMETIC/ PLASTIC SURGERY...................................................................................................... 49
8
BARIATRIC SURGERY (inc referral form)
....................................................................................... 27
50
Page 2 of 51
1
INTRODUCTION
This document sets out the Policy and Procedure for both NHS Southampton and NHS Hampshire with
respect to treatments which are not normally funded. These may be treatment requests or referrals made
either to an NHS provider outside the local health economy; to a provider where there is no contract in
place; generally for a treatment/ procedure that is excluded or to a non-NHS provider i.e. the private sector.
These referrals will, for the purposes of the Policy, be known as Individual Funding Requests (IFRs).
BACKGROUND
The NHS Confederation definition of an individual funding request in " Priority setting: managing individual
funding requests."
Is as follows:"A request to a PCTS to fund healthcare for an individual who falls outside the range of services and
treatments that the PCTS has agreed to commission.
There are several reasons why a PCTS may not be commissioning the healthcare intervention for which
funding is sought.
- It might not have been aware of the need for this service and so has not incorporated it into the
service specification
- It may have decided to fund the intervention for a limited group of patients that excludes the
individual for whom the request is made
- It may have decided not to fund the treatment because it does not provide sufficient clinical benefit
and/or does not provide value for money
- It may have accepted the value of the intervention but decided it cannot be afforded in the current
year
Such requests should not be confused with
- Decisions that are related to care packages for patients with complex healthcare needs
- Prior approvals which are used to manage contracts with providers"
2
REFERRALS TO BE DEALT WITH UNDER THE POLICY - EXCEPTIONALITY
If, a clinician believes that the case of an individual patient is so singular as to justify funding for an IFR,
they may apply for the case to be considered individually.Such cases are known as “exceptional”.
Exceptionality - this is best expressed by the question ‘On what grounds can the PCTS justify funding a
particular patient over and above others from the same patient group who are not being funded?’
The NHS Confederation guide ‘Priority setting: managing individual funding requests’ 2008 clarifies
exceptionality as:
In making a case for special consideration, it needs to be demonstrated that:
- the patient is significantly different to the general population of patients with the condition in
question, and
- the patient is likely to gain significantly more benefit than might be normally expected for patients
with the same condition
The fact that the treatment is likely to be efficacious for a patient is not, in itself, a basis for exceptionality.
In the event that an IFR is approved, this does not necessarily set any precedent and relates to the
individual patient only.
3
POLICY SCOPE
. In general this policy covers
- High, Medium and Low Priority Statements
Page 3 of 51
-
healthcare not normally purchased
drugs and devices outside of national tariff
IFRs are addressed by a lead manager, commissioning colleagues, members of the public health
directorate and a clinically-led joint Referral Panel.
Treatments that require Prior Approval for Funding due to their high cost or uncertain cost effectiveness
may on occasion be dealt with by the same decision making group. However, it is expected that the PCT
has specific conditions whereby permission is granted. Where there is uncertainty as to whether those
conditions are met then they may be dealt with by the IFR process. A list of treatments excluded from
funding and thus will require IFR application can be found at Appendix 2.
NB. The PCTs comply with mandatory Technology Appraisal Guidance published by the National Institute
for Health and Clinical Excellence (NICE)
This Policy does not address therapies provided purely as a part of clinical research. Research is funded
through designated research monies and has a separate management and governance framework. R&D
should not be supported from allocations intended for provision of mainstream health services, except
where agreed and negotiated via the Research Management and Governance consortium and in line with
national policy.
Conditions for submission to the IFR panel
The patient should be registered with a GP practice belonging to the relevant PCTs or, if not
registered with any GP, lives within the geographical responsibility of the PCTs and is eligible for NHS
treatment. If this is not clear then the Responsible Commissioner guidance from the Department of
Health should be consulted and applied
The provider can meet the waiting time target and quality standards as per Healthcare Assurance
Standards / Care Quality Commission guidelines
Only an NHS GP, NHS GDP or NHS Consultant can make a funding request. Allied health
professionals and specialist nurses can also make referrals though these should be endorsed by a GP
or consultant.
The procedure/treatment is not already purchased under existing service agreements.
Patient Choice guidelines will apply where relevant.
For a treatment covered under this policy and the PCTs have a contract covering a relevant specialty,
the referral should be made by a consultant of the same specialty to a provider with whom the PCTs
holds a contract.
Where an IFR is required, referrers are asked to consult with the PCTs to see if there is a contract in place
with the provider.
The PCTs would only consider a specialist referral on the recommendation of a local clinician from the
relevant specialty, where there was no appropriate NHS provision or where local NHS resources were no
longer able to meet the needs of the patient. Treatment in the private sector will only be considered where
there is evidence that NHS provision has been fully explored and exhausted.
Private treatment - If a patient has opted to pay for treatment and/or procedures privately, these will not be
funded retrospectively and this includes any future continued treatment by the private provider.
4
ROLE OF SHIP PRIORITIES COMMITTEE
The SHIP (Southampton, Hampshire, Isle of Wight, Portsmouth) Priorities Committee working on behalf of
the constituent PCTs develop and agree clinical policies using an ethical decision making framework and
standard procedures, supported by Solutions for Public Health (http://www.sph.nhs.uk/sph-psu/policyrecommendations/ship-policies) The policies are advisory and only become active when a constituent PCT
endorses them through its usual approval processes. For Hampshire PCT this is through its Professional
Advisory Committee. For Southampton this is through its Clinical Leadership Board. An index of agreed
Page 4 of 51
policy statements can be found at http://www.hampshire.nhs.uk/about-us/346-commissioning-policies and
www.southampton.nhs.uk. The PCTs may have considered a treatment to be a low priority against other
competing healthcare priorities within a limited resource envelope. Not all statements are adopted by the
individual PCTs.
Adopted statements are maintained by the constituent PCTs, are public facing and easily available to
clinicians.
5
DECISION-MAKING FRAMEWORK
The PCTs have the power to make decisions in commissioning services for its population. It must be
shown to act within its powers and reasonably. Decisions can be challenged by Judicial Review in terms of
legality, reasonableness or natural justice. There is therefore a decision making framework in place to
guide the IFR panel.
The PCTs decision making is based on the document at Appendix 4 – the South Central Ethical Framework
which covers the following;
- evidence of clinical and cost effectiveness
- equity
- healthcare need and capacity to benefit
- cost of treatment and opportunity costs
- needs of the community
- policy drivers
- exceptional need
This framework has been developed to support robust and transparent ethical decision-making and has
been agreed and adopted by all nine PCTs in NHS South Central.
Assessing individual cases
The following information should be used by the PCTs’ IFR panel to assess individual cases.
 Background to the case
 The patient’s problem and circumstances of the case
 Previous treatment and funding
 Proposed treatment and provider details
 Consideration of similar cases which have been dealt with in the past (but not as setting of
precedents)
 Current contracting arrangements
 Funding
 Contracts and providers
 Exclusions
 Relevant commissioning policies
 Comparison
 Information on what is happening elsewhere (particularly PCTs within the Strategic Health Authority
area)
 Advice from the South Central Priorities Committees
 Corporate view
 Views and position of interested parties (patient, patient body, carers, health professionals,
politicians, media)
Clinicians are involved in the decision making through the IFR panel. Minutes of the panel are reviewed and
signed off by the Chair of the Panel.
Page 5 of 51
6
PROCESS
A flowchart is included for clarity
Clinician feels patient
should be considered for
the panel
Clinician completes
form – primary and
secondary care forms
will differ
Taken through Prior
approval process
Form triaged by IFR
team
Clarity sought from
referrer, chair, delegated
clinician or relevant
commissioning or public
health advice
Referred to IFR panel
Decision made and
conveyed to
referrer/patient
All requests should be in writing using the IFR funding request form (found at appendix 1 and available on
the NHS Hampshire and NHS Southampton City website at http://www.hampshire.nhs.uk/about-us/346commissioning-policies and www.southampton.nhs.uk and supported by;
 a clear description of the exceptional circumstances, based on overriding clinical need,
 copies of any relevant correspondence; and
 other supporting documentation e.g. robust evidence of clinical and cost effectiveness,
consultant and other specialist assessments, appropriate costings.
Referrals must be submitted on the appended form together with all supporting documentation such as
relevant clinical history, correspondence from treating specialists and relevant published evidence base. In
the first instance, referrers should consider whether the referral is covered by local NHS provision, whether
there is a contract in place and that the referral is not contrary to the referral controls set out in this policy.
The referral must be clinically led. The PCTs will not accept direct patient requests, or routinely enter into
any correspondence with patients and/or their families unless as part of the statutorily applied NHS
Complaints Procedure. The PCTs will provide advice to patients regarding the process and recommend
they contact their GP or consultant. The referring clinician should act as the patient’s representative and
responses to funding requests will be made direct to the referrer. Where a request is declined, the PCTs
Page 6 of 51
recognise their obligations under the NHS Constitution to explain decisions to the patient but maintain the
importance of the referring clinician’s role in explaining clinical issues and rationale.
Before reaching the Panel, all requests will be addressed by the IFR Lead and, in cases where the referral
clearly does not meet the exceptional circumstances set out within the exceptions policy, set out in
Paragraph 2 above will be declined with a letter of explanation. The IFR lead will approve all referrals that
clearly meet the criteria set out in this policy. In cases where the referrer has not made the application on
the PCTs’ IFR funding request form and/or has not sent all relevant information plus any supporting
documentary evidence, the referrer will be invited to do so, to enable the request to proceed.
Those referrals to be considered by the Panel should be exceptional within the guidelines of current policy.
The Panel may also consider cases for a treatment not provided for within the policy and, where the
consequences of a decision might have wider implications on PCT policy may refer such cases to the
‘parent’ Appeals Panel for the relevant PCTs.
All requests, requiring a decision by the Panel together with supporting information will be submitted to the
next available meeting. Papers should be circulated at least one week prior to the meeting date.
The IFR Lead will share Panel decisions with neighbouring PCTs via a monthly report made to the SHIP
Priorities Committee.
Referrals leading to a possible policy change, those in an area of contention, or appeals against a Panel
decision where no additional information has been provided may be considered by the Appeal Panel for the
relevant PCTs.
For a cancer patient the panel may feel that the patient does not qualify for treatment on exceptional
grounds, In which case the case will be referred to the SHA’s Cancer Drug Fund panel. (Appendix 7)
Urgent cases
In exceptional circumstances where an urgent decision is required i.e. treatment cannot be delayed and/or
the patient’s disease is rapidly progressing it may be necessary for the Panel to consider a case virtually i.e.
via e-mail or conference call. Decisions will need to be clearly recorded and conveyed with a final decision
based on consensus and Chair’s action.
Page 7 of 51
7
HAMPSHIRE AND SOUTHAMPTON CITY JOINT REFERRAL PANEL
In order to meet the demand from the volume of referrals, the PCTs have a structure of a joint Referral
Panel and ‘parent’ Appeal Panels for each PCT.
Panel remit
It is important that all decisions made by Panels are transparent, defendable and consistent, observing PCT
corporate principles, available NICE guidance, advice from the SHIP Priorities Committee and the available
evidence base. After a decision has been made, a full written explanation will be provided to the referrer
and patient.
All referrals should be directed to the IFR team. All referrals received via other routes should be passed to
the IFR team. The IFR team will:
 Convey information
 Manage the panel meeting agenda
 Record Panel decisions
 Triage applications
Where the IFR team is unclear how to triage an application as the information may be complex or unclear
advice may be sought from a range of expert advice e.g. Children’s, mental health or dental commissioning
advice who may in turn seek advice from members of the Panel or elsewhere. This advice should be
recorded. Referrals may be returned to the referrer for greater clarification.
A summary of the referrals made, details of the request and outcome of decisions will be logged each
month. Where a significant number of referrals are being made in a particular area or specialty these will be
flagged to the PCTs.
Membership (Joint Hampshire and Southampton Referrals Panel)
The Panel should consist of primary care clinicians, the IFR lead or member of his team, an associate
director / key contracting manager (Contracting) and a public health consultant. The Panel should be
chaired by a senior clinician or public health consultant.. Where appropriate, support should be secured
from a medicines management lead and a nursing professional depending on the cases considered. A
guide to membership is as follows to ensure clinical participation.
Chair (either a GP or public health consultant)
Public Health Consultant
Associate Director / Key Contracting Manager (Contracting)
At least 2 local clinicians/ GPs
Nursing/pharmacy representation (as and when required)
Commissioning/ IFR lead
Minute taker to record decisions
The Panel will meet twice a month for which there should be a minimum of 3 clinicians/allied health
professionals as a quorum. Additional members may be co-opted as the need arises. The key task of the
Panel is to consider and discuss individual cases and to decide to approve funding, reject a request or defer
to seek further information. It is intended that the Panel should have representation from both PCTs at
each meeting but will act as a decision-making body on behalf of both PCTs. Ideally the chair should rotate.
Page 8 of 51
8
PCT APPEALS PANELS
The GP/clinician has a responsibility to refer appropriately. Good working relationships should ensure that
proper procedures are followed. However, the referrer may wish to appeal against a decision and this
should initially be made in writing to the IFR Lead with additional supporting information/evidence. If the
information provided contains new evidence the referral should be reconsidered by the original Panel. If
their decision remains unchanged the referral will be directed to the relevant PCTs Appeals Panel.
Draft terms of reference and membership
The Appeals Panels for both NHS Hampshire and NHS Southampton City will remain to consider appeals
from referring clinicians on behalf of patients from their relevant PCTs. The Appeals Panel will have the
same remit of the Joint Referral Panel but receives funding requests/cases that have already been
considered by that Panel and are subject to challenge. New information within an appeal should be
considered by the original Panel.
In some cases, the Panel may wish to refer ‘upwards’ to the relevant Appeals Panel for one of the following
reasons:
 any funding decision might impact on commissioning policy or would have a bearing on future
commissioning decisions across SHIP; or
 decisions that might be subject to formal legal challenge and/or political/media involvement which
affect the reputational risk of the organisation(s)
9
PCT APPEAL BODY
If the decision in an individual IFR request made by either the Panel or Appeals Panel is appealed against
by the referring clinician, there is a further opportunity to appeal to the NHS Hampshire final appeals body.
The Appeals Body comprises of:
 the Chief Executive of the PCT
 the Executive Director of Public Health
 a PCT non-executive Director / Chair of the PCT Board (chairing)
A member of the original decision-making Panel may also attend to present the audit trail of the case being
considered but would not have a vote in any decision made. Clinical colleagues may be co-opted onto any
Panel depending on the subject matter.
The role of the Appeals Body is to judge whether the process and framework by which a funding decision is
made was fair, equitable and based on the evidence available at the time. It does not take funding
decisions itself and, if any new evidence is brought before it, this must be referred back to the previous
Panel. Should the Appeals Body overturn the decision of a Panel, then funding would be expected to
follow. The grounds for funding decisions need to be accepted as relevant to meeting the overall
healthcare needs of the population within resource constraints.
The PCTs will not accept appeals instigated by a patient, their family or other non-clinical representative
(e.g. local MP).
At both the initial referral and appeal stages, cases will be considered with the GP/other referring clinician
being the main point of contact. The decision of the PCTs Appeals Body is final.
Complaints
Patients have the right to raise a formal complaint with the PCT using the NHS Complaints Procedure
should they be unhappy with the PCTs handling of their case (i.e. staff attitude, communication or the way
in which the policy or procedure has been followed, adherence to procedure). The NHS Complaints
Procedure is set out to address concerns over service provision and not funding decisions. It cannot be
Page 9 of 51
used to investigate or influence funding decisions and the appropriate process for appeals should be
followed i.e. from the referring clinician and not the patient.
10
SERVICE DEVELOPMENTS
NHS Hampshire and Southampton City will not introduce new interventions through the individual funding
request mechanism. The NHS Contract makes it clear that the hospital provider is expected to seek funding
for new treatments through submission of a business case to the commissioner (Schedule 6, point 8.3).
There is, therefore, an expectation that new treatments will be properly assessed and prioritised. It is not
rational for a PCT to manage a new treatment by considering one patient at a time nor would this be fair,
because it breaches a principle commonly adopted by PCTs, namely that:
‘The PCT does not offer treatment to a named individual that would not be offered to all patients with equal
clinical need’.
NHS Confederation –Priority setting: managing individual funding requests, 2008
11
IMPLEMENTATION OF NICE GUIDANCE
NICE guidance is published as a series of Technology Appraisal Guidance documents, Clinical Guidelines,
and Interventional Procedures Guidance. These documents are distributed widely within the NHS. The
guidance is also available on the NICE web site at www.nice.org.uk. It should be noted that guidelines
and Interventional Procedures guidance are not mandatory. Only Technology Appraisal Guidance
published by NICE as mandatory carries a duty to make funding available to implement within 3
months of the publication date, unless otherwise stated.
Provider contracts take account of a limited percentage – the NICE uplift - to meet the estimated costs of
implementation in secondary care. The assumptions used to estimate the reserve involve a significant
degree of financial risk. Moreover, this reserve is top-sliced from any growth monies at the beginning
of the year. Thus, the cost of funding NICE recommendations has a direct impact upon the ability to
fund competing priorities for service development.
In light of the above factors it is essential that interventions approved by NICE are used only in accordance
with the published criteria. The secondary care clinician should provide evidence that the criteria are met.
If published NICE guidance is likely to have significant resource implications for the local NHS,
implementation may be delayed for a period of 3 months from the date of publication. This is to
enable the necessary administrative arrangements to be put in place. However, the PCTs accept
that delayed implementation may not be appropriate for rapidly progressive conditions where delay
is likely to compromise the clinical outcome significantly.
The NICE reserve does not cover the costs of implementation of NICE guidance in primary care. The
funding for this is included within the annual uplift to primary care prescribing budgets.
As per Department of Health guidance, the above does not preclude the PCTs from funding health
interventions that are not subject to finalised NICE guidance or are currently in the NICE process awaiting
guidance. Appropriate procedures for consideration should still be taken.
12
MANAGING THE ENTRY OF NEW DRUGS
Relevant District Prescribing Committees (DPCs) or Area Prescribing Committees (APCs) are responsible
for considering whether new drugs and preparations are suitable for local use. The DPCs/APCs are joint
bodies formed with members from provider Trusts and the PCTs. The use of drugs not approved by
DPCs/APCs is not generally supported.
Page 10 of 51
If a referrer wishes to propose that a drug or preparation be considered for use by clinicians locally, a formal
application should be made to the Chief Pharmacist. Additions to the formulary should represent a
significant advance over current therapy. The application should be supported by any relevant published
research evidence. The application forms can be found at the front of the Joint Formulary file.
There is no reserve to meet the costs of introducing new drugs (other than those approved by NICE) within
the financial year. If a new drug is supported by the DPC/APC and agreed formally by the PCTs, the costs
of its introduction will need to be met from existing resources. This applies equally whether the drug is
prescribed within secondary care or in primary care. Where the costs cannot be absorbed, the addition of
the drug to the Formulary may need to be deferred until resources allow. Cost pressures on the secondary
care drugs budget are negotiated through the annual Operating Plan.
The PCTs commission appropriate drug therapy as an integral part of patient care. Individual drugs should
not be excluded from contracts as a separate cost item.
Page 11 of 51
Page 12 of 51
Appendix 1: Prior approvals
Where procedures are either high cost, falling outwith specialised commissioning or cost effectiveness of a procedure is only high when certain
criteria are met then the PCTs request prior approval of those procedures. These are known as the Restricted Procedures.
Procedures that require the use of the prior approval tool
For secondary care consultants, prior approval for a number of common but restricted surgical procedures should be applied for via a secure webbased tool at https://priorapproval.hampshire.nhs.uk Those procedures earmarked for, or already on, the tool are marked with an asterisk(*)
below. This will need to be applied for in advance of the treatment being provided. The Map of Medicine tool also provides information on these
procedures and thresholds for referral. This list has been prepared by public health. This list is not exhaustive and will be updated regularly.
Where policy criteria are met – as described within the tool – instant approval is obtained and a printout made. This will mean that, for certain
procedures, the full paper application need not be completed unless the patient does not meet the policy criteria. If patient does not meet the policy
criteria and a clinician is of the opinion that a patient is clinically exceptional, an Individual Funding Request will need to be submitted to the IFR
team in line with the IFR Policy
There are currently seven procedures but a significant number of procedures from the core exclusions list will be added to the tool. The current
procedures are:
Specialty
Low priority procedure
OPCS code(s)
Guidance on exceptions / exceptions criteria
ENT
*Grommet insertion for
children
D151
1. Treatment with grommets will be funded for children with disabilities
such as Downs Syndrome and Cleft Palate where the insertion of
grommets is part of an established pathway of care.
2. Treatment with grommets will be funded for children to treat a
tympanic membrane retraction pocket.
3. Treatment with grommets will be funded for children aged over 3 years
old with Otitis Media with Effusion (OME) and without a second disability
(such as Downs Syndrome or Cleft Palate) when:
There has been a period of watchful waiting for three months in
primary care from diagnosis of OME in primary care, followed by a
further period of watchful waiting for up to three months in ;
secondary care; and
OME persists after the three-six months of watchful waiting; and
The child has documented speech or language delay or
Page 13 of 51
Specialty
Low priority procedure
OPCS code(s)
Guidance on exceptions / exceptions criteria
behavioural problems; and
The child has a documented hearing level in the better ear of 2530dBHL or worse averaged at 0.5, 1, 2 and 4kHz (or equivalent
dBA where dBHL not available)
ENT
*Grommets in adults
D151
This procedure is not routinely funded for adults (≥ 18 years old) except
under the following conditions:
- A middle ear effusion causing measured conductive hearing loss,
persisting for at least 6 months and resistant to medical treatments. The
patient must be experiencing disability due to deafness. The possible
option of a hearing aid may be discussed, at the discretion of the
clinician.
- Persistent Eustachian tube dysfunction resulting in pain (e.g. flying)
- As one possible treatment for Meniere’s disease.
- Severe retraction of the tympanic membrane if the clinician feels this
may be reversible and reversing it may help avoid erosion of the
ossicular chain or the development of cholesteatoma.
- Grommet insertion as part of a procedure for the diagnosis or
management of head and neck cancer and/or its complications
ENT
*Tonsillectomy
F34F361
Tonsillectomy will be funded
- in children and adults for cancer or suspected cancer; or
- in children and adults for cases of quinsy; or
- in children and adults for obstructive sleep apnoea where other
treatments have failed or are inappropriate; or
- in children and adults for tonsillitis if all of the following criteria are met:
 Sore throats are due to tonsillitis
 There are 5 or more episodes of sore throat per year (confirmed in
Primary Care)
 There have been symptoms for at least a year
 Episodes of sore throat are disabling and prevent normal
functioning
Page 14 of 51
Specialty
Low priority procedure
OPCS code(s)
Guidance on exceptions / exceptions criteria
ENT
*Bone-anchored hearing
aids
D131-9
Considered in patients over the age of 5 years who:
 Have abnormalities of the middle, outer or external parts of the ear or
a chronic ear infection, which makes wearing a conventional hearing
aid difficult or impossible.
 Have a hearing loss in both ears that cannot be operated on and for
which conventional hearing aids are not felt to be suitable.
 Can hear sounds well via bone conduction.
 Can understand 60% or more of speech on a standard test using
bone conduction.
 Are able to keep the area around the fixture clean, alone or with help.
Varicose veins
*Varicose vein procedures
L84-,
L85-,
L86L87-,
L88-
This will be commissioned in accordance with the South Central Priorities
Committees policy statement. Varicose vein surgery will be funded in
people with a body mass index less than 32 who satisfy at least one of
the following criteria:
 a recurrent venous ulcer
(OR)
 a first venous ulcer which persists despite a six-month trial of
conservative management (compression stockings, exercise and
daily elevation two to three times a day)
(OR)
 haemorrhage from a superficial varicosity
Treatment in all other circumstances is LOW PRIORITY and not routinely
commissioned.
Surgical treatment may be with ligation and stripping, phlebectomy and/or
foam sclerotherapy. All techniques which involve heating the vein
(whether by laser, radio-frequency, microwave or any other means) are
LOW PRIORITY and not routinely commissioned.
Gynaecology
*Dilatation and Curettage
Q103/8/9
Dilatation and Curettage alone should not be used as a diagnostic tool
and should not be used as a therapeutic procedure.
Dilatation and curettage will be funded if either of the following criteria are
met:
The patient has had outpatient negative pressure endometrial sampling
(e.g. Pipelle™ sampling) with an unsatisfactory histological result
Page 15 of 51
Specialty
Low priority procedure
OPCS code(s)
Guidance on exceptions / exceptions criteria
Or
The patient has had a hysteroscopy and endometrial biopsy with an
unsatisfactory histological result
Gynaecology
*Hysterectomy in heavy
menstrual bleeding/
dysmennorhea
Q07- (except Q076),
Q08-
Hysterectomy for heavy menstrual bleeding or dysmenorrhoea will be
funded if all the following criteria are met:
Other treatments for heavy menstrual bleeding (in accordance
with NICE Clinical Guideline 44 “Heavy Menstrual Bleeding”) or
dysmenorrhoea such as a Mirena coil have failed or are
contraindicated; and
There is a wish for amenorrhoea; and
The woman no longer wishes to retain her uterus and fertility
2. Hysterectomy for the treatment of uterine problems amenable to
surgery but are not related to heavy menstrual bleeding or
dysmenorrhoea will be funded
Urology
*Male circumcision
N303
This procedure should only be considered in
cases of pathological phimosis where inability to retract the foreskin is
due to permanent scarring of the preputial orifice. In boys with lower
urinary outflow obstruction and/or with recurrent urinary tract infection
(particularly where high grade vesico-ureteric reflux is present)
circumcision as an option for potentially reducing further infection should
be discussed with parents and boys able to give informed consent. In the
absence of medical urgency, the procedure should not be undertaken
until the boy is old enough to give informed consent. Circumcision may
also occasionally be required in the management of penile carcinoma.
MSK/ Pain
management
*Facet Joint Injections (FJI)
for Chronic Low Back Pain/
spinal epidurals for nonradicular pain/ sciatica/ RFthermal denervation of
facet joint
V544
A521/2
A573
A604
A781/2/3
V481/3/5/7
1) Facet joint injections are not routinely commissioned for patients with
diagnosed chronic non specific low back pain.
2) Medial branch blockade will be funded for the diagnosis of cervical,
thoracic and lumbar back pain when all the following criteria are met:
a) The pain has resulted in moderate to significant impact on daily
Page 16 of 51
Specialty
Low priority procedure
OPCS code(s)
Guidance on exceptions / exceptions criteria
functioning; AND
All conservative management options including psychologically based
treatments have been attempted or a patient may not be suitable due
to:
o communication difficulties
o Cognitive impairment
o Documented difficulty in tolerating medicines
3) Conventional Radiofrequency lesioning preceded by a positive median
nerve diagnostic block can be considered at this point & the patient is
part of a comprehensive pain management programme including
physiotherapy, psychosocial support, medication and patient education.
Facet joint pain is confirmed by controlled diagnostic local anaesthetic
block; and
 The pain has lasted for more than one year; and
 The pain has resulted in moderate to significant impact on daily
functioning; and
 All conservative management options (bed rest, physiotherapy
guided exercise, pharmacotherapy including analgesia and
muscle relaxants) have been tried and failed; and
 The patient is part of a comprehensive pain management
programme including physiotherapy, psychosocial support,
medication and patient education.
Repeat injections:
Repeat injection will be funded if the individual has benefitted by
maintaining function for > 6 months.
Orthopaedics
*Trigger finger surgery
T723
Surgery will be commissioned for patients diagnosed with trigger finger:
• who fail to respond to conservative treatment, including no response
following one corticosteroid injection
• who have a fixed flexion deformity that cannot be corrected
• moderate to severe pain/locking sufficient to cause interference with
hand function
• persistent symptoms > 3 months
Orthopaedics
Carpal tunnel release/
A65-
In line with DoH pathway
Page 17 of 51
Specialty
Low priority procedure
OPCS code(s)
nerve entrapment at wrist
Guidance on exceptions / exceptions criteria
http://www.pathwaysforhealth.org/xpath2007/xeditor/publisher.asp?d_ref
=910220D9BE124C78830F324EFEE93A38&
Orthopaedics
*Lavage and debridement
of the knee in patients with
osteoarthritis
W852
a. Where the patient has clear mechanical symptoms (not gelling, ‘giving
way’ or X-ray evidence of loose bodies).
b. When information is required regarding the degree and distribution of
joint damage, enabling informed decision making regarding the type of
knee replacement that could be performed (partial or total knee
replacement).This can be of particular help in young patients with
osteoarthritis
Ophthalmology
*Chalazia (meibomian
cysts)
C121
In line with Thames Valley (Berkshire PCTS’s) Priorities Committee
Policy
Chalazia (meibomian cysts) are benign, granulomatous lesions that will
normally resolve within 6 months. Treatment consists of regular (four
times daily) application of heatpacks.
Excision of chalazia will be funded when all of the following criteria are
met:
- The chalazia has been present for more than 6 months
- Where it is situated on the upper eyelid
- Where it is causing blurring of vision
Oral surgery
Wisdom teeth extraction
F091/3
As per NICE guidance and will only be accepted where access to
secondary care skills and facilities are required such as:
 The tooth has complex anatomical configuration
 There is pathology associated with the tooth which may
complicate the procedure
 Patient has medical complications which make management
inappropriate in primary care.
*Dental implants
F088/9
F115/6
1. To restore oral function for patients who have received treatment
for head and neck cancer, or other extensive oral pathology or
trauma.
2. To support head and neck and oral prosthesis for patients who
have received treatment for head and neck cancer, or other
extensive pathology or trauma.
Page 18 of 51
Specialty
Low priority procedure
OPCS code(s)
Guidance on exceptions / exceptions criteria
3. To restore oral function for patients with rare genetic or inherited
conditions e.g. severe hypodontia (more than six missing teeth),
cleft lip and palate
4. To restore oral function for edentulous patients when conventional
prosthetic dental procedures will, in the considered opinion of a
consultant in restorative dentistry, fail due to lack of bone support,
neuromuscular control, or other medical conditions.
Plastic surgery
*Removal of excess skin
following weight loss
S02S03 -
In order to be considered for plastic surgery, patients should meet all of
the following criteria:
1. The patient’s starting BMI before weight loss must have been no
less than 45kg/m2 (the threshold for access to bariatric surgery in
HIOW).
2. The patient’s BMI must be less than 30kg/m2.
(In some patients a BMI of less than 30kg/m2 may not be
achievable, due the weight of excess skin. In these circumstances
an exception to the policy may be considered, provided that the
patient has lost at least 50% of their excess weight, and their
clinician confirms that no further reduction in BMI will be possible
without removal of excess skin.)
3. The patient’s weight must have been stable for a minimum of 2
years,
4. There must be documented evidence of clinical pathology or
disability due to the skin fold in question (eg recurrent infection,
intertrigo, cellulites, restricted mobility, inability to undertake
physical exercise to maintain cardiovascular fitness). Purely
cosmetic procedures, such as removal of surplus skin from the
arms, will not be considered.
Plastic procedures other than abdominoplasty, mammoplasty, and
removal of skin folds from the inner thighs will not normally be funded.
Gynaecology
Reversal of sterilisation/
vasectomy
N18Q29Q37-
In circumstances of the death of a partner or only child or where
sterilisation caused by proven surgical accident that was not a foreseen
consequence of such a procedure.
Page 19 of 51
B: Procedures where prior approval is required but the prior approval tool is not in use
These are lower volume high cost procedures or treatments where the need is relatively rare but whose use is restricted to certain indications.
Provided the criteria are met, the PCT will simply require a proforma as notification indicating patient detail, procedure and where the criteria are
met. This will not require the full application form. In recognition of individual Trusts having different notification proforma, the PCT will accept
individual formats provided the relevant information included. Where the criteria are not met, then a full application will be required before treatment
can go ahead.
Gastro-enterology
Sacral nerve stimulation in
faecal incontinence and
constipation
A701-4 PLUS site
Z112 Sacral nerve
and/or
Y705 for temp
electrodes
Sacral nerve stimulation should be offered only to people with faecal
incontinence who have ALL FOUR of the following characteristics:
Gastric fundoplication for
chronic reflux oesophagitis
G241 and G243
This applies in reflux oesophagitis only
 severe incontinence of liquid or solid faeces (at least one
episode per week)
 a structurally intact but functionally deficient anal sphincter
 an unsatisfactory response to all appropriate non-surgical
treatments and any previously attempted surgical ones
 a satisfactory response to a test procedure.
The procedure should only be performed by clinicians designated by the
commissioner with a specialist interest in the assessment and treatment
of faecal incontinence who follow NICE’s guidance on this interventional
procedure.
Funded exceptions are where adults have at least one of the following
characteristics
-
regular, significant symptoms of gastro-oesophageal reflux
despite receiving at least one year of continuous pharmacological
treatment up to the maximum dose licensed for reflux
oesophagitis
-
significant volume reflux placing them at risk of aspiration
-
anaemia because of oesophagitis
Its use in other circumstances of reflux oesophagitis is a low priority
Orthopaedics
Vertebroplasty
V444
Vertebroplasty for the treatment of pain due to vertebral body fracture
which is refractory to conservative, medical treatment can be a
treatment option for selected patients. The procedure must be
performed in line with NICE Interventional Procedure Guidance.
Page 20 of 51
The clinician performing the procedure is an accredited interventional
spinal radiologist, who is suitably trained and experienced and that data
is collected and submitted to the UK Vertebroplasty registry supported by
Liverpool University.
Indications for Percutaneous Vertebroplasty
• Osteoporotic vertebral compression fractures more than FOUR
weeks old in the cervical, thoracic, and lumbar spine causing
moderate to severe pain and unresponsive to conservative
therapy
• Painful metastasis and multiple myelomas with or without adjuvant
radiation or surgical therapy
• Painful fractures due to vertebral hemangiomas
• Painful fractures due to vertebral osteonecrosis
•Reinforcement of a pathologically weak vertebral body before a
surgical stabilization procedure
Palmar fasciectomy
/Dupuytren’s contracture
T521-2
T541
Referral for surgical opinion should only be made in the following
circumstances:
• patient has a contracture and cannot flatten their fingers or palm on a
table
• there is functional impairment
Ophthalmology
Eyelid surgery/
blepharoplasty
C13C16C18-
Where affecting visual fields.
Specialist dentistry
Secondary orthodontic
treatment
F14F15-
Orthognathic surgery
As per Hampshire & IOW NHS Orthodontic Care Pathway (see NHS
Orthodontic Care – Area Referral Panels, Guidance for General Dental
Practitioners). Orthodontic care is subject to a separate triage process
established in 2008 and circulated to general dental practice
Considered for the following categories of patients provided there is one
of
1. Marked facial asymmetry
2. Congenital facial syndromes including Cleft Lip and Palate and Pierre
Robin
3. Significant skeletal jaw discrepancies causing difficulties with eating
and/or speaking
4. Severe orthodontic malocclusions that cannot be corrected by a
Page 21 of 51
course of fixed appliances alone
Endodontic treatment
F13/F17
For those who, in the opinion of a consultant in restorative dentistry, need
endodontic treatment to maintain or restore oral function for a successful
long-term outcome
AND there is no other consideration that may affect successful long-term
outcome
AND can demonstrate maintenance of good oral health
Periodontal treatment
F136, F164/7, F635
All the following criteria must be demonstrated
Those who are in pain or have significant and intractable periodontal
problems for whom periodontal treatment in general dental care has not
achieved significant benefits,
- for whom specialist periodontal treatment is likely to confer significant
health gain;
- can demonstrate maintenance of good oral health;
- do not smoke at time of referral;
- there are no other significant factors within the control of the patient that
may affect a successful outcome.
Advanced restorative
dental
F08-
Considered to replace permanent teeth missing post major trauma, post
cancer treatment or significant congenital absence to allow patient to
masticate effectively.
Infertility treatments
In vitro fertilisation
(including the prescriptions
of infertility drugs) and ICSI
(intracytoplasmic sperm
injection)
Ophthalmology
Short sight/long sight
corrective (laser) surgery
Opthalmology
Anti-vascular endothelial
growth factors (VEGFs) for
any indication and
bevacizumab for diabetic
retinopathy, diabetic
macular oedema and
retinal vein occlusion
As per the South Central Specialised Commissioning Group policy
criteria
C461
May be considered where laser or operative correction is the only
treatment available to restore reasonable visual acuity/or where there are
substantial other medical reasons that make correction by external visual
aids inappropriate.
The use of anti-VEGFs for age-related macular degeneration is covered
by NICE TAG155.
The South Central Priorities Committees policy states that bevacizumab
should be made available for all indications other than ‘wet’ age-related
macular degeneration, diabetic retinopathy, diabetic macular oedema
and retinal vein occlusion (central or branch), subject to clear
Page 22 of 51
(central or branch)
arrangements for commissioning and evaluation of outcomes.
Plastic surgery/ ENT
Rhinoplasty
EO2EO36-7
E072/3/8/9
Only in cases of post-surgical reconstruction following trauma or for
congenital malformation
Plastic surgery
Dermabrasion, chemical
peels and laser treatment
S601/2,
S091/2, S103, S113
Only for disfiguring burnt out acne where there has been previous
specialist treatment
Mental health
Inpatient treatment for
chronic fatigue syndrome
Vascular
Endoscopic thoracic
sympathectomy for
hyperhydrosis or excessive
facial blushing
A752, A762, A772,
A782, A792
Facial blushing is often a result of social phobia and is encouraged by an
over-active sympathetic nervous system. There is limited evidence
suggesting that Endoscopic Thoracic Sympathectomy can control the
occurrence of facial blushing and sweating, however, the patient is likely
to experience adverse side effects.
• It is recommended that other methods be sought to cure the symptoms.
• If the procedure is performed the patient should be informed before
operating that the probability of compensatory sweating is extremely high
and very likely.
Pain Management
Electronic spinal cord
stimulator implants for
management of pain
Pain Management
In-patient pain
management programme
Bariatric surgery for morbid
obesity
Mental health
The anti-cholinesterase
inhibitors (AChEIs)
donepezil, galantamine
and rivastigmine for the
treatment of dementia
A483-7
Considered only following failure of other interventions for chronic pain in
patients following failed back surgery, complex regional pain syndrome
and patients with angina who are not suitable for revascularisation. Must
be part of a multi-disciplinary pain management approach including
consideration of CBT.
Chronic non cancer pain diagnosis confirmed by specialist pain
physician, mental health needs optmised, local treatment options
exhausted, local clinical psychologist feels is suitable candidate, own GP
confirms approval.
G27, G28, G30, G31,
G32, G33, G87,
G481/2, G716
In accordance with service specification managed by South Central
Specialised Commissioning Group policy and their own separate funding
application form (see Appendix D)
The AChEIs donepezil, galantamine and rivastigmine should be available
as an option to treat patients with dementia associated with Parkinson’s
disease or dementia with Lewy Bodies if they have noncognitive
symptoms causing:

significant distress to the individual (for example visual
Page 23 of 51
associated with
Parkinson’s disease or
Lewy Bodies Dementia

hallucinations)
or leading to behaviour that challenges
This is in line with NICE-SCIE Clinical Practice
Guideline 42.
A701-4 (plus Z126)
Neurology
Electrical Stimulation
(including Functional
Electrical
Stimulation) for Upper and
Lower Limb Dysfunction
Respiratory
Short Burst Oxygen
Therapy for the Relief of
Episodic Breathlessness
Patients should only be considered treatment with SBOT for the relief of
episodic breathlessness

If all other treatment options have been tried

When the diagnosis is clear and the underlying condition is
already being treated optimally

Following objective assessment including a record of oxygen
saturation by a clinician with a special interest and training in the
management of respiratory diseases

Existing patients on SBOT will need to be properly reviewed and
assessed by a Specialist Respiratory Assessment Service so that the
home oxygen therapy that they receive is the most appropriate for their
condition, for the right period of time and with appropriate flow rates to
obtain optimal benefits and reduce the chance of adverse effects.
Specialist assessment is essential prior to any changes in oxygen
therapy service being suggested or implemented. These changes may
mean that some patients are assessed for LTOT/ambulatory oxygen
therapy.
Endocrine
Human growth hormone
(somatropin) in adults with
growth hormone deficiency
Recombinant human growth hormone (somatropin) treatment is
recommended for the treatment of adults with growth hormone (GH)
deficiency only if they fulfil all three of the following criteria:
This is low priority in accordance with the South Central Priorities
Committee policy statement for treatment of unilateral foot drop following
a neurological event as part of rehabilitation. Where there is a trial
service run by specialist neuro-rehabilitation service, an AFO splint is not
tolerated, the patient has sufficient cognitive function, it objectively
improves function or prevents falls. It is expected that the local specialist
team will manage the rehabilitation and stimulator.
 They have severe GH deficiency, defined as a peak GH response of
less than 9 mU/litre (3 ng/ml) during an insulin tolerance test or a crossvalidated GH threshold in an equivalent test.
 They have a perceived impairment of quality of life (QoL), as
Page 24 of 51
demonstrated by a reported score of at least 11 in the disease-specific
‘Quality of life assessment of growth hormone deficiency in adults’ (QoLAGHDA) questionnaire.
 They are already receiving treatment for any other pituitary hormone
deficiencies as required.
This is in line with NICE guidance TA64.
HIV
Maraviroc and Raltegravir
in the management of
human immunodeficiency
virus type 1 (HIV-1)
infection resistant to
standard therapy
Maraviroc
For treatment-experienced adults infected only with CCR5-tropic
HIV1 in accordance with the BHIVA guidance; and
 for patients with triple class infections; and
 can only be initiated after discussion by a group consisting of a
minimum of 3 consultants, an HIV pharmacist and virology input
Raltegravir is a LOW PRIORITY for first line treatment in adult patients
but, in combination with other anti-retroviral drugs may be used
 for patients with triple class infections; and
 can only be initiated after discussion by a group consisting of a
minimum of 3 consultants, an HIV pharmacist and virology input
For those procedures not listed on the tool but remaining on the exclusions list within the Policy, the normal funding application procedure applies.
Page 25 of 51
THRESHOLDS COMMISSIONING
Clinical threshold management has been introduced by NHS Hampshire and NHS Southampton City to reduce variation and ensure that elective
procedures accessed by patients are at the most appropriate time and consider the entire clinical pathway. The Map of Medicine tool supports this
process and is available through NHS Athens accounts. Reduced variation will improve fairness to patients and allow optimum use of funding.
Thresholds on activity currently exist for cataract surgery as detailed below but a significant number of procedures from the core exclusions list will
be added to the list of volume threshold procedures. If a patient does not meet the threshold policy criteria and a clinician is of the opinion that a
patient is clinically exceptional, an Individual Funding Request will need to be submitted to the IFR team in line with the IFR Policy
Specialty
Low priority procedure
Ophthalmology
Cataract surgery
(threshold criteria)
Guidance on exceptions / exceptions criteria
C71C72C73C74C75-
GPs should refer patients with cataracts that accord with Royal College
of Ophthalmologist’s referral principles and meet the following criteria.
Optometrists will have carried out the appropriate assessments and
referred back to GP for onward referral to secondary care. A copy of the
optometrist report (GOS18 or suitable referral form) must be included
with the referral.



Patients should be referred where 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
Reduced to 6/18 or worse irrespective of the acuity of the other
eye OR:
The patient wishes to/is required to drive and does not meet
Driving and Licensing Authority (DVLA) eyesight requirements.
NB: In the presence of cataract, glare may prevent the ability to
meet the number plate requirement, even with apparently
appropriate acuities.
Any suspicion of cataracts in children (e.g. altered or absence of red
reflex at neonatal or 6 week check) should be referred urgently
Page 26 of 51
Appendix 2: EXCLUDED PROCEDURES
The following list is not exhaustive and will be subject to regular change as and when evidence is published and priority advice is taken around
commissioning. It is for the referring clinician to provide detail of exceptional circumstances as per the appended form in light of the earlier definition
of exceptionality provided by the NHS Confederation. Guidance notes are included where appropriate and only as a pointer towards consideration.
The recommendations and policy notes of the South Central Priorities Committees will supersede or add to this list as will mandatory
NICE Technology Appraisal Guidance. The list below is under constant review and development.
Specialty
Procedure
Plastic/ cosmetic
procedures
surgery (see
Appendix C for
further detail)
Any procedure carried
out for primarily
cosmetic reasons is
excluded i.e. not funded
OPCS
codes
Notes
See Appendix C
Rhinophyma correction
E094/6
Treatment of ganglions
T59 T60-
Treatment of bunions
(hallux valgus)
W791/2
W151
Liposuction/lipectomy
(including apronectomy)
and submental lipectomy
S031/2/3
S621/2
S013
Face/ brow/ buttock/ thigh/
upper arm lift
S01- (not
S013)
S031/2/3
Breast augmentation
surgery or correctional
procedures
B30B31-
As per the South Central Priorities Committee policy statement. Post cancer
treatment is an exception to this policy and will go ahead as part of established
cancer pathways without the need for prior approval
Mastopexy (repositioning
of nipple)
B35- (not
B355)
Only as part of post-surgical reconstruction
Breast reduction surgery
B311
Page 27 of 51
Specialty
Procedure
OPCS
codes
Pinnaplasty
D03-
Notes
Labiaplasty
Removal of benign skin
lesions and blemishes
including skin tags
anywhere on the body
E094,
H482,
S04-,
S05-,
S06-,
S08-,
S09-,
S10- (not
S103)
S11-
Concern over malignancy will be an absolute exception and should go ahead without
application for prior approval subject to clinical audit
Alternative/
complementary/
homeopathic
therapies
Complementary medicine
X61-
When included as an adjunct to usual therapy – not funded as a separate procedure
Gender dysphoria
 Psychological
assessment
 Gender reassignment
Laser hair removal
 Vocal chord shaving
X15-
Consideration following full psychiatric assessment by local services. Referrals,
following asssessment, to the Charing Cross Gender Identity Service only (meeting
ICD10 criteria) and made directly by the relevant mental health team. This service is
commissioned by the South Central Specialised Commissioning Group
Mental health
Inpatient psychotherapy
Non-NHS residential
placements
Adult ADHD and
Aspergers’
Orthopaedics
On an individual patient basis
Sports limbs
Hip resurfacing
W581,
Z843
Kyphoplasty
V445
Page 28 of 51
Specialty
Procedure
OPCS
codes
Notes
X521
Emergency decompression only
Appliances and devices for
cosmetic purposes (highgrade silicon cosmesis
and/or prosthesis)
Glucosamine (sulphate
and hydrochloride salt) for
adult osteoarthritis
Serum P1NP
measurement in the
management of
osteoporosis
Other
Hyperbaric oxygen therapy
(HBOT)
Co-careldopa intestinal gel
(Duodopa) for advanced
Parkinsons’ disease
Penile implants for erectile
dysfunction
Low priority as per SHIP Priorities Committee policy statement
Cerebellar stimulator
implants in spasticity
Low priority due to lack of evidence of clinical effectiveness
Single-incision sub-urethral
short tape insertion for
stress urinary incontinence
in women
M533/4/5
Excluded as per NICE Interventional Procedures Guidance 262
Silver releasing dressings
for management of chronic
wounds
Page 29 of 51
Specialty
Procedure
OPCS
codes
Notes
Polysomnography in the
investigation of children
with sleep-related
disorders
U331
This policy does not apply to the use of PSG in the management of complex
craniofacial abnormalities through the nationally commissioned and designated
craniofacial service.
Trans-catheter aortic
valve implantation for
aortic stenosis
K358,
Y013, Y53,
Z322 –
femoral
approach
K262, Y494
apical
approach
In line with the South Central Priorities Committee policy statement. New evidence
may become available about this procedure, in which case the policy will be reviewed.
Trans-cranial Doppler
ultrasonography with
frequent transfusion to
prevent stroke in children
with sickle cell disease
Growth Hormone for
children born small for
gestational age (SGA)
If the procedure is funded in exceptional circumstances, the commissioning
framework endorsed by the British Cardiovascular Intervention Society1 recommends
that it should only be at hospitals carrying out at least fifty trans-catheter aortic valve
implantations for aortic stenosis per year.
Cannabinoids in the
management of Multiple
Sclerosis and chronic pain
Eculizumab for the
management of
Paroxysmal Nocturnal
Haemoglobinuria (PNH)
Therapeutic use of
probiotics in adults and
children
1
Sethi S. Daniel T, Howell J, Griffen C. A commissioning framework for transcatheter aortic valve implantation (TAVI) for severe symptomatic aortic stenosis.
(www.bcis.org.uk/resources/documents/TAVI%20National%20Commissioning%20Framework
%20FINAL%20160309.pdf)
Page 30 of 51
Specialty
Laser treatments
Procedure
OPCS
codes
Use of neuro-stimulators in
the management of
essential tremor, primary
dystonia, and multiple
sclerosis.
A09
Pulmonary vein isolation
(PVI) for arterial fibrillation
K621
PVI should be restricted to patients for whom alternative therapies have proved
ineffective, as outlined in the NICE interventional procedure guidance on PVI.
Warts, rosacea, scars,
thread veins/venous flares,
spider naevia,
telangiectasia, seborrhoeic
keratoses, portwine stains,
benign lesions, hair
removal, resurfacing
Y088
Y113/Y133,
S065,
S091/2
Routinely excluded but exceptional (particularly facial) disfigurement considered.
Clinical photography would normally be required subject to patient consent
Tattoo removal
S091/2
S065/8/9
Cardiothoracic
surgery
Closure of patent foramen
ovale
Oncology
Extra-corporeal
photopheresis for the
treatment of chronic graft v
host disease or cutaneous
T-cell lymphoma
Salvage cryotherapy for
recurrent prostate cancer
Notes
This policy does not apply to closure of patent foramen ovale for stroke prevention.
M671
Cryotherapy for localised
prostate cancer
Page 31 of 51
Specialty
Procedure
Sorafenib for
Hepatocellular Carcinoma
(HCC)
OPCS
codes
Notes
In line with NICE Single Technology Guidance 189, issued July 2010:
‘Sorafenib is not recommended for the treatment of advanced hepatocellular
carcinoma in patients for whom surgical or locoregional therapies have failed or are
not suitable.
People currently receiving sorafenib for the treatment of advanced hepatocellular
carcinoma should have the option to continue treatment until they and their clinician
consider it appropriate to stop’.
Cyberknife surgery for
cholangiocarcinoma
Page 32 of 51
Appendix 3: SOUTH CENTRAL ETHICAL FRAMEWORK
Berkshire East PCT
Berkshire Priorities Committee (BPC)
Berkshire West PCT
Buckinghamshire PCT
Buckinghamshire and Milton Keynes
Priorities Committee (BMKPC)
Milton Keynes PCT
Oxfordshire PCT
Oxfordshire Priorities Forum (OxPF)
Hampshire PCT
Hampshire and Isle of Wight Priorities
Committee (HIOWPC)
Isle of Wight PCT
Portsmouth City Teaching PCT
Southampton City PCT
South Central Specialised Services Commissioning Group (SCG)
Central South Coast and Thames Valley Cancer Networks (CN)
Background
The Priorities Committees are committees of representatives of the NHS organisations across all nine
South Central NHS Primary Care Trusts (PCTSs) and include lay members as well as clinicians and
managers. The purpose of the ‘Priorities Committees’ is to advise the local NHS health economy as to the
health care interventions and policies that should be given high or low priority.
Primary Care Trusts are under a statutory duty to promote the health of the local community. They are also
under a duty not to exceed their annual financial allocation. These legal requirements mean that, from time
to time, difficult choices have to be made. The Priorities Committees help PCTSs choose how to allocate
their resources to promote the health of the local community. Individual cases are considered by each
respective PCTS.
A review of the existing ethical frameworks of the Thames Valley and Hampshire and Isle of Wight has
contributed to the development of a South Central wide ethical framework to support decision making
across all of South Central both within the established Priorities Committees and also within the
SCG/networks or individual PCTSs. For the purposes of this document, all the above organisations will be
referred to collectively as the ‘Committees’.
Purpose of the Ethical Framework
The purpose of the ethical framework is to support and underpin the decision making processes of
constituent organisations and their Priorities Committees to support consistent commissioning policy
through:
 Providing a coherent structure for discussion, ensuring all important aspects of each issue are
considered
 Promoting fairness and consistency in decision making from meeting to meeting and with regard
to different clinical topics, reducing the potential for inequity
 Providing a means of expressing the reasons behind the decisions made.
 Reducing risk of judicial review by implementation of robust decision-making processes that are
based on evidence of clinical and cost effectiveness and an ethical framework
 Supporting and integrating with the development of PCTS Commissioning Plans
Formulating policy recommendations regarding health care priorities involves the exercise of judgment and
discretion and there will be room for disagreement both within and outwith the Committees. Although there
is no objective or infallible measure by which such decisions can be based, the Ethical Framework enables
decisions to be made within a consistent setting which respects the needs of individuals and the
community. The Committees recognise that their discretion may be affected by National Service
Frameworks, National Institute for Health and Clinical Excellence (NICE) technology appraisal guidance
and Secretary of State Directions to the NHS.
Page 33 of 51
The Ethical Framework is especially concerned with the following:
1.
EVIDENCE OF CLINICAL AND COST EFFECTIVENESS
The Committees will seek to obtain the best available evidence of clinical and cost effectiveness using
robust and reproducible methods. Methods to assess clinical and cost effectiveness are well established.
The key success factors are the need to search effectively and systematically for relevant evidence, and
then to extract, analyse, and present this in a consistent way to support the work of the Committees.
Choice of appropriate clinically and patient-defined outcome needs to be given careful consideration, and
where possible quality of life measures and cost utility analysis should be considered.
The Committees will promote treatments for which there is good evidence of clinical effectiveness in
improving the health status of patients and will not normally recommend treatment that is shown to be
ineffective. Issues such as safety and drug licensing will also be carefully considered. When assessing
evidence of clinical effectiveness the outcome measures that will be given greatest importance are those
considered important to patients’ health status. Patient satisfaction will not necessarily be taken as
evidence of clinical effectiveness. Trials of longer duration and clinically relevant outcomes data may be
considered more reliable than those of shorter duration with surrogate outcomes. Reliable evidence will
often be available from good quality, rigorously appraised studies. Evidence may be available from other
sources and this will also be considered. Patients’ evidence of significant clinical benefit is relevant.
The Committees will compare the cost of a new treatment to the existing care provided and will also
compare the cost of the treatment to its overall benefit, both to the individual and the community. They will
consider technical cost-benefit calculations (e.g. quality adjusted life years), but these will not by
themselves be decisive. The Priorities Committees may use the ethical framework to guide context-specific
judgements about the relative priority that should be given to each topic.
2. EQUITY
The Committees believe that people should have access to health care on the basis of need. There may
also be times when some categories of care are given priority in order to address health inequalities in the
community. However, the Committees will not discriminate on grounds of personal characteristics, such as
age, gender, sexual orientation, gender identity, race, religion, lifestyle, social position, family or financial
status, intelligence, disability, physical or cognitive functioning. However, in some circumstances, these
factors may be relevant to the clinical effectiveness of an intervention and the capacity of an individual to
benefit from the treatment.
3. HEALTH CARE NEED AND CAPACITY TO BENEFIT
Health care should be allocated justly and fairly according to need and capacity to benefit, such that the
health of the population is maximised within the resources available. The Committees will consider the
health needs of people and populations according to their capacity to benefit from health care interventions.
So far as possible, it will respect the wishes of patients to choose between different clinically and cost
effective treatment options, subject to the support of the clinical evidence.
This approach leads to three important principles:



In the absence of evidence of health need, treatment will not generally be given solely because a
patient requests it.
A treatment of little benefit will not be provided simply because it is the only treatment available.
Treatment which effectively treats “life time” or long term chronic conditions will be considered
equally to urgent and life prolonging treatments.
4.
COST OF TREATMENT AND OPPORTUNITY COSTS.
Because each PCTS is duty-bound not to exceed its budget, the cost of treatment must be considered. The
cost of treatment is significant because investing in one area of health care inevitably diverts resources
from other uses. This is known as opportunity costs and is defined as benefit foregone, or value of
opportunities lost, that would accrue by investing the same resources in the best alternative way. The
Page 34 of 51
concept derives from the notion of scarcity of resources. A single episode of treatment may be very
expensive, or the cost of treating a whole community may be high.
5.
NEEDS OF THE COMMUNITY
Public health is an important concern of the Committees and they will seek to make decisions which
promote the health of the entire community. Some of these decisions are promoted by the Department of
Health (such as the guidance from NICE and National Service Frameworks). Others are produced locally.
The Committees also support effective policies to promote preventive medicine which help stop people
becoming ill in the first place.
Sometimes the needs of the community may conflict with the needs of individuals. Decisions are difficult
when expensive treatment produces very little clinical benefit. For example, it may do little to improve the
patient’s condition, or to stop, or slow the progression of disease. Where it has been decided that a
treatment has a low priority and cannot generally be supported, a patient’s doctor may still seek to
persuade the PCTS that there are exceptional circumstances which mean that the patient should receive
the treatment.
6.
POLICY DRIVERS
The Department of Health issues guidance and directions to NHS organisations which may give priority to
some categories of patient, or require treatment to be made available within a given period. These may
affect the way in which health service resources are allocated by individual PCTSs. The Committees
operate with these factors in mind and recognise that their discretion may be affected by National Service
Frameworks, NICE technology appraisal guidance, Secretary of State Directions to the NHS and
performance and planning guidance.
Locally, choices about the funding of health care treatments will be informed by the needs of each individual
PCTS and these will be described in their Local Delivery Plan.
7.
EXCEPTIONAL NEED
There will be no blanket bans on treatment since there may be cases in which a patient has special
circumstances which present an exceptional need for treatment. Each case of this sort will be considered
on its own merits in light of the clinical evidence. PCTSs have procedures in place to consider such
exceptional cases on their merits.
Authors:
Date of Issue:
Review Date:
South Central Priorities Support Unit Steering Group
12th February 2008
1st February 2011
Page 35 of 51
INDIVIDUAL FUNDING REQUEST (IFR) APPLICATION FORM
SECONDARY CARE USE
Please note it is the clinician’s responsibility to obtain patient consent to share this and all supporting materials with
the PCT. All information will be used and stored in accordance with the data protection act. Photographic evidence,
where appropriate, may be submitted separately using only the minimum data set (GP details, initials, DOB and NHS
number) to ensure patient confidentiality
On completion the request form and all supporting materials as defined within this request form should be posted,
faxed or emailed to the IFR team – contact details included at the end of this form.
All sections are to be completed in requests from secondary care and specialist provider services. In recognition of
the nature of requests from primary care those sections denoted by an asterisk (*) are to be completed at the
discretion of the requesting general practitioner.
CONTACT INFORMATION
Trust / General Practice Surgery
Name
1. Address
2. Applicant Details
Name:
Designation:
Tel:
Email:
3. Patient Details
Name:
Hospital ID number:
NHS Number:
DoB:
Registered Consultant:
Registered GP name:
Registered GP postcode:
Referred by (other than
GP):
Referred from:
4. Application reviewed by Chief
Pharmacist or nominated
deputy (in the case of a drug
intervention)
Date of referral:
Name:
Signature or email
confirmation:
Page 36 of 51
STATEMENT CONFIRMING APPROPRIATENESS FOR CONSIDERATION AS AN IFR
If it is foreseeable that there are one or more other patients within the PCTs’ population who are or are likely to be
in the same or similar clinical circumstances as the requesting patient in the same financial year, and who could
reasonably be expected to benefit to the same or a similar degree from the requested treatment then the request
should properly be considered as a request for a service development and inappropriate for consideration as an
IFR except in the circumstances where all the similar patients are expected to be from the same family group, a
situation which may arise in the context of a rare genetic disease.
5. I confirm that it is not
expected that there will be
more than one patient from
within the PCTs’ population
who is or is likely to be in the
same or similar clinical
circumstances as the
requesting patient in the
same financial year and who
could reasonably be
expected to benefit to the
same or a similar degree
from the requested treatment
unless similar patients are
expected to be from the same
family group.
Tick box as appropriate
Yes
 No
DIAGNOSIS AND PATIENT’S CURRENT CONDITION
6. Patient Diagnosis (for which
intervention is requested)
(a) In case of cancer:
What is disease status? (e.g.
at presentation,1st/2nd or 3rd
relapse)
What is the WHO performance
status? (*)
How advanced is the cancer?
(stage)
Describe any metastases:
(b) In case of non-cancer:
What is the patient’s clinical
severity? (Where possible use
standard scoring systems e.g.
WHO, DAS scores, walk test,
cardiac index etc.)
(c) For all conditions (i.e.
cancer and non-cancer)
Please summarise the current
status of the patient in terms of
quality of life, symptoms etc
INTERVENTION REQUESTED (NB: Intervention refers to requested treatment, investigation, etc)
Page 37 of 51
7. Details of intervention (for
which funding is requested).
If the intervention forms part
of a regimen, please
document the full regimen
(e.g. Drug X as part of regimen
Y (consisting of drug V, drug
W, drug X and drug Z).
Regarding anticipated cost
Acute Trusts to provide this
from finance departments and
primary care to seek advice
from their Practice Based
Commissioning Locality
Manager.
8. Is requested intervention part of
a clinical trial?
Name of intervention:
Dose and frequency (*):
Planned duration (*)
Of intervention:
Route of administration
(*):
Anticipated cost (inc
VAT)
Are there any offset
costs? (*)
Describe the type
and value of the
offset costs (*)
Funding difference
being applied for (*)
Delete as appropriate: Yes/No (refer to
pharmacy if required)
Delete as appropriate: Yes / No
If Yes, give details (e.g. name of trial, is it an MRC/National trial?)
Is the drug funded through a clinical trial?
Delete as appropriate: Yes / No
a) What would be the standard
intervention at this stage?
b) What would be the expected
outcome from the standard
intervention?
c) What are the exceptional
circumstances that make the
standard intervention
inappropriate for this patient?
d) Please explain how this
individual has an exceptional
ability to benefit from the
requested intervention over and
above another individual with the
same condition.
e) If the requested intervention
was not available what would
your next planned intervention
be?
10. Summary of previous
intervention(s) this patient has
received for the condition.
Dates
Intervention (e.g.
drug / surgery)
Reason for stopping /
Response achieved
Reasons for stopping may include
Page 38 of 51
(not exclusively):
 Course completed
 No or poor response
 Disease progression
 Adverse effects/poorly
tolerated
11. Anticipated start date
Processing a request usually takes up to 2 weeks from the date
received by the PCTs. If the case is more urgent than this, please state
why:
EVIDENCE OF CLINICAL EFFECTIVENESS
12. Where the intervention is a
drug / medicine is the
requested drug / medicine
licensed for the requested
indication in the UK?
13. Has the Trust Drugs and
Therapeutics Committee or
equivalent Committee
approved the requested
intervention for use? (if drug or
medical device) (*)
14. Give details of National or
Local Guidelines /
recommendations or other
published data / evidence
base supporting the use of the
requested intervention for this
condition? (*)
Delete as appropriate: Yes / No (refer to pharmacy if required)
Delete as appropriate: Yes / No
If No, Committee Chair or Chief Pharmacist approved: Yes / No
PUBLISHED2 trials / data (Please forward papers / web links for peerreviewed papers where available. This needs to be supplied for all
secondary care and specialist provider requests – the request will not
be considered if these have not been included.)
(a) How will you monitor the
clinical effectiveness of this
intervention?
(b) Detail the current status of
the patient according to these
measures.
(c) What would you consider to
be a successful outcome for this
intervention in this patient?
(d) What is the minimum time
frame/course of treatment at
which a clinical response can be
assessed? (e.g. after a single
course of treatment)
15. What is the anticipated toxicity
of the intervention for this
patient?
16. Are there any additional clinical
factors of the patient that need
to be considered not already
Delete as appropriate: Yes / No
If Yes, please give details:
2 Full published papers, rather than abstracts, should be submitted
Page 39 of 51
included in 8c or 8d?
17. Form completed by
Name:
Signature or email confirmation:
PCT use only
Record of communication:
Points for Discussion

Recommendation:

Date:
Contact details for IFR Submissions
All applications should be made using the Individual Funding Request Application Form and
provide all the required information as outlined in the Funding Request Form. The form
should be completed electronically / typed – hand written submissions will not be accepted.
Submissions should be sent (by post or fax or email) to:
Individual Funding Request team
NHS Hampshire
Omega House
112 Southampton Road
Eastleigh
Hants SO50 5PB
Tel: 02380 623254/5/6
Fax: 02380 620343
E-mail: [email protected]
Page 40 of 51
INDIVIDUAL FUNDING REQUEST (IFR) APPLICATION FORM
FOR USE IN PRIMARY CARE
Contact details for IFR Submissions
All applications should be made using the Individual Funding Request Application Form and
provide all the required information as outlined in the Funding Request Form. The form
should be completed electronically / typed – hand written submissions will not be accepted.
Please ask your Practice Manager to load this form onto your practice server for ease of use.
General guidance can be found directly below but, if you have any questions as to whether to
submit an application or regarding the form itself, please contact the IFR team on the number or
email address below as this may well save you a lot of time! General enquiries without patient
identifiable data can also be emailed to [email protected]
Submissions should be sent (by post or fax or email) to:
Individual Funding Request team
NHS Hampshire
Omega House
112 Southampton Road
Eastleigh
Hants SO50 5PB
Tel: 02380 623253/5/6
Fax: 02380 620343
E-mail: [email protected]
Page 41 of 51
General guidance on completion
We recognise that the IFR application form is not easy to complete and that you may not complete it often.
We have therefore devised a shorter format than the application form previously available which we have
now reserved for secondary care. The guide below should avoid requests for additional information and
delays in decision-making. As set out above, please contact the team on the details above if you have any
queries.
The list below details some of the top 10 referrals received last year and the information required by the
PCTs to make an informed decision
Breast reduction – this will require details of patient’s BMI, breast size, confirmation that patient has had a
professionally fitted bra, evidence of any intervention to address symptoms e.g physiotherapy for posture,
details of how quality of life is affected. Psychological issues and distress are consistently not supported
by the clinical Panel as a deciding factor on funding.
Breast augmentation for asymmetry, lack of breast development or tubular breast development –
this is routinely considered as a ‘cosmetic’ procedure and has no direct physiological clinical benefit. In this
case, clinical photography – as with any ‘plastics’/’cosmetic’ procedure may well be a useful adjunct to an
application compared to a written description. Although this cannot be insisted upon due to the sensitivity
of such requests and patient consent, Panels find this a very useful aid to decision-making. Photographs
are stored securely and anonymously to ensure patient confidentiality and will be returned on request.
Abdominoplasty - guidance regarding this procedure for removal of excess skin following massive weight
loss is included in NHS Hampshire’s Policy and Procedure for IFRs found on our website at
http://www.hampshire.nhs.uk/about-us/346-commissioning-policies under the paragraph marked ‘noncontractual referrals’. We receive many cases for this procedure particularly following multiple Caesarean
sections and there is little evidence to support direct physiological benefit.
Pinnaplasty – the PCTs receive many requests for this procedure in children suffering from teasing and
bullying at school. This is no longer commissioned routinely and the Referral Panel, whilst sympathetic with
such cases, regrettably does not approve requests based on a child’s distress.
Bariatric surgery – this is managed by the South Central Specialised Commissioning Group on a
separate application. This can be accessed either via the number above or direct from the South Central
SCG on 023 8062 7284 or by emailing [email protected]. The PCTs’ IFR policy and procedure of
which the application below is part of includes a bariatric referral form in the appendices.
IVF – access to IVF is also managed by the South Central SCG to regional policy criteria. In short, this is
restricted to childless couples where the woman is aged between 30 and 34 and following either diagnosis
of absolute infertility or three years of attempting to start a family where there is no clear diagnosis.
Referrals meeting the criteria can only be made by a secondary care fertility specialist. Cases outside the
criteria that you deem exceptional can be made to the PCTs using the form below.
Asperger’s/autism diagnosis in adults – we expect that all such patients have had a baseline mental
health assessment by the local adult mental health team to exclude other co-morbidities. The PCTs have
arrangements in place to organise specialised assessments on a named patient basis. A summary of the
patient’s daily functioning and social situation and how such an assessment may benefit should be
submitted – the application form need not be completed but could act as a guide. Please contact the IFR
team to discuss.
Varicose veins – the policy criteria governing access to varicose vein treatment are clear and evidencebased. The link between symptoms reported by many patients e.g heaviness, aching, itching and varicose
veins; and hence surgical intervention are not supported by the evidence. For more detail, NHS
Page 42 of 51
Hampshire has an excellent summary on ‘Pages4Primary Care’ which explores this and can be shared
with your patient.
Functional electrical stimulation (FES) – this is a particularly common request to treat ‘dropped foot’ for
neurological problems (eg stroke, MS) and may well be due to the local presence of the national FES
Centre in Salisbury. This has been extensively reviewed on at least two occasions by the South Central
Priorities Committees and, whilst agreed as a more ‘elegant’ approach to dropped foot in terms of greater
walking speed/distance and lower fatigue, it is not a cost-effective option for the local NHS. Our Panel
reviews on a named patient basis particularly where the standard use of ankle-foot orthosis has been
proven to be intolerant or where there is a falls history/risk.
PATIENT INPUT
Direct patient applications cannot be accepted by the PCTs but patient accounts may be included in the
application should they wish to contribute towards their case. We would expect GPs to act on their
patient’s behalf and to make necessary enquiries. Any appeals should also be clinically-led.
SECONDARY CARE APPLICATIONS
We would encourage primary care clinicians to request specialists/ secondary care consultants to complete
funding applications themselves for treatments that require specialist intervention, expertise or opinion. We
would support all Practices should there be any problems in obtaining secondary care support in
completion of funding applications which we would expect to come directly from the Trusts themselves.
Page 43 of 51
IFR APPLICATION FORM
PRIMARY CARE USE ONLY
Nb Secondary care clinicians please complete usual funding application form
Please note it is the clinician’s responsibility to obtain patient consent to share this and all supporting materials with
the PCTS. All information will be used and stored in accordance with the Data Protection Act.
CONTACT INFORMATION
GP and Surgery Name
1. Address inc. postcode
2.
Position:
Tel:
Email:
3. Patient Details
Name:
NHS Number:
DoB:
Date of referral:
DIAGNOSIS AND PATIENT’S CURRENT CONDITION
4. Patient Diagnosis (for which
intervention is requested)
Diagnosis
Please summarise the current status of the patient in terms of
quality of life, symptoms etc
INTERVENTION REQUESTED (NB: Intervention refers to requested treatment, investigation, etc)
Page 44 of 51
5. Details of intervention (for
which funding is requested)
If costs are known, please state
(optional)
Name of intervention:
6 Is the requested treatment
available locally? (state where if
possible)
7 Are there any clinical factors
that need to be considered that
would set this patient out as
exceptional?
The following is an excerpt from
the NHS Confederation guide
‘Priority setting: managing
individual funding requests’
2008 which clarifies this:
Exceptionality - this is best expressed by the question ‘On what
grounds can the PCTs justify funding a particular patient over
and above others from the same patient group who are not
being funded?’
THIS IS THE MOST IMPORTANT PART OF THE APPLICATION
AND WOULD EXPECT THE MOST DETAIL TO BE INCLUDED
HERE
In making a case for special
consideration, it needs to be
demonstrated that:
- the patient is significantly
different to the general
population of patients
with the condition in
question, and
- the patient is likely to
gain significantly more
benefit than might be
normally expected for
patients with the same
condition
The fact that the treatment is
likely to be efficacious for a
patient is not, in itself, a basis
for exceptionality.
Social and psychological
circumstances, whilst
recognised, are not considered
decisive factors in funding
For more detail please refer to
the case studies here
thttp://www.phcn.nhs.uk/case
book/2/PHCN%20Casebook
%20Issue%202,%20p1%20E
xceptionality%20guidance.do
c
Page 45 of 51
8 Summary of previous
intervention(s) this patient has
received for the condition.
Dates
Intervention
Reason for stopping /
Response achieved

9 Please summarise any
additional supporting information
and attach all relevant clinical
correspondence in support of
the application
10 Form completed by
Name:
Signature or email confirmation:
Page 46 of 51
Appendix 6
SOUTH CENTRAL STRATEGIC HEALTH AUTHORITY CANCER DRUG FUND
From 1 October 2010 cancer patients will have greater access to the cancer drugs that their doctors
recommend for them due to an extra £50 million in funding being made available nationally by the
Department of Health.
Following Health Secretary Andrew Lansley's announcement in July, an extra £50 million will be made
available across the UK to allow thousands of patients to receive innovative new cancer drugs that may
extend life or improve quality of life.
Clinically led panels have been set up in each region, putting doctors in charge of deciding how this funding
is spent for their patients locally, together with advice from relevant cancer specialists. The funding will be
available until the end of March 2011 when a further cancer drugs fund scheme will be introduced.
In the NHS South Central region, the portion of additional cancer funding amounts to £3.4m.
A specialist panel, chaired by Dr Peter Hockey, Deputy Medical Director South Central SHA, has been
formed to deal with requests from doctors for additional cancer drug funding.
Members of the panel are drawn from a pool of volunteers consisting of:
 Oncologists
 Haematologists
 GPs
 Public Health consultants
 Palliative care consultants
The chair will select appropriate members according to specialist expertise and area of interest of panel
members. At least one site-specialist expert for each application being considered will be included in the
panel
When an application for funding is received the chair will identify appropriate members from the pool. The
panel will consider applications within ten working days of receiving the application and communicate the
outcome to the referring specialist. The referring specialist will be invited to present the case for funding, but
will not be included in the decision making process.
Frequently Asked Questions:
How much money is available for the new Cancer Drug Funding across the South Central Region?
The figure for NHS South Central is £3.4m
Why has this money been made available?
This is additional funding for cancer drugs. It is intended to enable individual patients to receive clinicallyrecommended treatments they have been unable to access following full consideration of funding options
by their PCTs. It provides a process that enables specialist clinicians to take treatment decisions for the
benefit of patients where funding for a cancer drug has been refused through usual commissioning
channels. This process is to implement the Secretary of State’s vision that oncologists should have greater
freedom to prescribe those cancer drugs which they believe to be in the best interest of individual patients.
Is this funding available every year?
This funding is an interim measure available from the 1 October 10 until 31 March 2011 although the
government has set out its plans to establish a further Cancer Drugs Fund from April 2011
How do clinicians access this funding for their patients?
Page 47 of 51
This is additional funding for cancer drugs. It is intended to enable individual patients to receive clinicallyrecommended treatments they have been unable to access following full consideration of funding options
by their PCTs
Application for funding is made to NHS South Central via the following link: [email protected]
Who sits on the specialist Panel?
The panel is chaired by Professor Peter Johnson, Professor of Medical Oncology, Cancer Research UK
Centre, Southampton General Hospital.
Applications will be considered by a clinical panel consisting of oncologists and haematologists plus
representation from primary care, public health and palliative care.
How will the panel decide on who gets funding?
The panel will assess requests based on a test of clinical ‘reasonableness’, which will include evaluation of
the evidence submitted to demonstrate the likelihood and extent of clinical benefit to the patient from the
drug treatment requested.
Who manages the Cancer Fund?
The fund is managed by South Central Specialised Commissioning who will support the panels, but will not
participate in the decision-making processes. Specialised Commissioning will be responsible for liaison
with PCTSs, to obtain evidence of their decisions on prior exceptional/individual funding requests, and to
ensure that the service costs of the drugs funded by the Panel will be met.
Do all Cancer patients have access to this fund?
Yes, although funding will be determined on a case by case basis.
Existing PCT funding routes should have been adequately explored and exhausted before a call is made on
SHA funds. This includes exploring PCT processes for considering individual / exceptional funding
requests.
Does the funding extend to radiopharmaceuticals?
Yes, the primary focus of the funding is on improving access to cancer drugs, which can include
radiopharmaceuticals.
Will there be any monitoring of the outcomes?
Yes, referring specialists will be asked to provide updates at 6 week intervals on the results of treatment.
Specialists who unreasonably fail to provide updates will not be able to apply for further funding by this
mechanism.
Does an appeals process exist if cancer funding is not agreed through this process?
Yes, a referring oncologist may appeal against the Panel’s decision within 2 weeks.
Who do I contact for further information?
Please contact:
Joanne Funderburk
Project Officer
Programme & Project Team
South Central Strategic Health Authority
First Floor, Rivergate House
Newbury Business Park
London Road
Newbury
RG14 2PZ
Email : [email protected]
Tel: 01635 275611
Page 48 of 51
APPENDIX 7
COSMETIC/ PLASTIC SURGERY
Overall the policy for funding of cosmetic/plastic surgery is that this is not normally funded and only
considered following surgery, trauma or for congenital malformation. (Post-surgical reconstruction would
be part of service level agreements for surgical services in any case.)
The effect of the problem on essential activities of day-to-day living is a key factor in decision-making. In
such cases, psychological treatment such as counselling or cognitive behavioural therapy may be
considered as an appropriate alternative to surgery.
It is not necessary to obtain a psychiatric opinion and this should only be sought at the specific request of
the PCTs. We would expect psychiatrists to treat related problems through established procedures that the
PCTs commission from the mental health trust and this would not include surgery.
Exceptions criteria in previous policies for procedures such as breast augmentation, breast reduction,
mastopexy, implant removal and replacement, gynaecomastia, pinnaplasty and abdominoplasty have been
removed with referrers asked to provide individual detail of exceptional circumstances and conditions in
line with the points above.
We would request that all applications for ‘plastics’ procedures should be accompanied by suitable clinical
photography that demonstrates the extent of the problem. This, of course, would be subject to patient
consent.
Page 49 of 51
APPENDIX 8
Bariatric surgery referral form
South Central Specialised Commissioning Group
GENERIC REFERRAL FOR BARIATRIC SURGERY ASSESSMENT
CHECK LIST FOR ELIGIBILITY
Statement to be signed by the referrer and sent to:
South Central Specialised Commissioning Group
Omega House
112 Southampton Road
Eastleigh SO50 5PB
Name of Referrer (please print):
_________________________________________________________
GP or NHS Trust Consultant:
__________________________________________________________
Address/Tel:
____________________________________________________________________
____________________________________________________________________
Postcode:
__________
PCT:
__________________________________
NHS No:
__________________________________
Provider’s Patient Reference: _____________________
Name: ______________________________ _____________________________________________________
Address:___________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Postcode: __________________
Date of Birth: ______________
(Age:
)
Home Telephone No: ________________________________
Work Telephone No:
________________________________
Mobile Telephone No: ________________________________
Patient’s GP: _______________________________________
Page 50 of 51
Criterion
Yes/No
Inclusion Criteria For Bariatric Surgery
1 BMI
_______________ (weight in kg divided by height squared in m2)

45 kg/m2 in the presence of serious co-morbidity which will be improved by bariatric surgery

60 kg/m2 in the absence of serious co-morbidity
2
The following conditions will be accepted as meeting the definition of a serious co-morbidity:

Established ischaemic heart disease (please give details)

Type 2 diabetes requiring oral medication or insulin (please state which)

Life-threatening sleep apnoea (please give details of investigations and present therapy)

Severe uncontrolled hypertension (please give average BP and list drugs)

Benign intracranial hypertension with severe, sight-threatening papilloedema (please give
details)

History of transient ischaemic attacks or stroke (please give details)

Severe lower limb major joint disease requiring orthopaedic intervention which is precluded
on safety grounds due to patient’s BMI (please state proposed surgical procedure)

Other co-morbid condition which has been agreed by the PCT as exceptional, on an
individual patient basis
3
The patient has been receiving intensive management by a specialist obesity service.
4
All available non-surgical measures have been tried, but have failed to maintain significant (ie
>10% ) weight loss.
5
There are no specific clinical contraindications and the patient is fit for surgery.
6
The patient has realistic expectations of the outcomes of surgery, and understands that
cosmetic plastic procedures to remove excess skin folds will not be funded by the NHS.
7
The patient understands the long term commitment and compliance required.
8
PCTs will consider requests for obese patients who fall outside these criteria to be offered
surgery in exceptional circumstances (eg where the patient has a BMI less than 45, but has
life-threatening co- morbid conditions which will be significantly improved by bariatric surgery.
Please provide clinical
details of any criteria
met by patient and
include list of
medication
Please give any other relevant information
I confirm that all the above appropriate access criteria have been met and this patient is therefore eligible for NHS
funded bariatric treatment.
Referrer’s signature: _____________________________Date of referral:
___________________
Page 51 of 51