Download The Individual Case Panel

The Individual Case Panel
Paul Hand-Griffiths
North East Clinical Governance Meeting
11th November 2011
Timeline and Terminology
• Bolton PCT created in 2002 - Effective Use of
Resources policy inherited from HA
• A formal Commissioning Panel implemented in
2004
• Effective Use of Resources/Commissioning
Framework for Individual Cases/Procedures of
Limited Clinical Value
• Commissioning Panel/Individual Request
Panel/Individual Case Panel
What is the policy? (1)
•
Outlines the process used to handle funding
requests
Commissioning Framework for Individual Cases
http://www.bolton.nhs.uk/Library/policies/COMM09.pdf
•
Details our position on funding drugs, devices and
procedures that are outside the range of services
normally commissioned by the PCT
Commissioning Policies: Individual Case Panel
http://www.bolton.nhs.uk/Library/policies/COMM11.pdf
What is the Policy? (2)
• Application - clinicians only
– BUT patient can include supporting information
Process (1)
• Screening Panel
– Triage – 20 or more cases per week
– Information!!!
• Application proforma vs. clinical letter?
– Test against policy
– Possible outcomes:
• Treatment agreed: policy/criteria or pathway
• Treatment refused: does not meet policy/criteria or pathway
• Decision deferred: insufficient information
• Full Panel: Exceptionality, prior approval or no policy
Process (2)
• Individual Case Panel
– Information!!!
– Exceptional?
The Commissioner does not offer treatment to a named individual that would
not be offered to all patients with equal clinical need. 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 from the intervention
than might be normally expected for patients with that condition
(after Dr Henrietta Ewart)
Process (2)
• Individual Case Panel
– Information!!!
– Exceptional?
The Commissioner does not offer treatment to a named individual that would
not be offered to all patients with equal clinical need. 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 from the intervention
than might be normally expected for patients with that condition
(after Dr Henrietta Ewart)
Process (3)
• Individual Case Panel (contd.)
– Individual? – prior approval
– No social factors
– Possible outcomes:
• Treatment agreed: clinical exceptionality
• Treatment agreed: prior approval criteria met
• Treatment refused: no exceptionality/criteria not met
• Decision deferred: insufficient information
Process (4)
• Process Review
– Membership – not the same
– Grounds for re-consideration
• New information
• Decision not within reasonable range of decisions
• Process and/or principles not followed
– Possible outcomes:
• Original decision upheld
• Individual Case Panel asked to reconsider case
– Note: cannot overturn original decision
Policies
• More policies = fewer cases to full Panel
BUT
• Ensuring compliance = the real task!
• Web-based version & quick guide
• nww.bolton.nhs.uk or www.bolton.nhs.uk > Your
PCT > Policies and Procedures > Commissioning
Case Study (1)
• Letter from a GP regarding a 65 year old male with
a BMI of 35 requesting surgery to correct
gynaecomastia. He has had a private consultation
with a plastic surgeon for an assessment and she
has said he would be suitable for surgery.
Case Study (1)
• Letter from a GP regarding a 65 year old male with
a BMI of 35 requesting surgery to correct
gynaecomastia. He has had a private consultation
with a plastic surgeon for an assessment and she
has said he would be suitable for surgery.
– Policy: this treatment is not funded
Case Study (1)
• Letter from a GP regarding a 65 year old male with
a BMI of 35 requesting surgery to correct
gynaecomastia. He has had a private consultation
with a plastic surgeon for an assessment and she
has said he would be suitable for surgery.
– Policy: this treatment is not funded
– Exceptionality? No evidence of:
• Clinical need for surgery
• Clinical reason for condition
Case Study (1)
• Letter from a GP regarding a 65 year old male with
a BMI of 35 requesting surgery to correct
gynaecomastia. He has had a private consultation
with a plastic surgeon for an assessment and she
has said he would be suitable for surgery.
– Policy: this treatment is not funded
– Exceptionality? No evidence of:
• Clinical need for surgery
• Clinical reason for condition
– Funding refused
Case Study (2)
• Letter received from Laserase Clinic in Bolton. 35
year old woman requesting laser removal of coarse
hair on the face and chest. No further clinical
information provided.
Case Study (2)
• Letter received from Laserase Clinic in Bolton. 35
year old woman requesting laser removal of coarse
hair on the face and chest. No further clinical
information provided.
– Information: GP approached for:
• Evidence of underlying endocrinological/other problem e.g.
PCOS or drug side-effect
Case Study (2)
• Letter received from Laserase Clinic in Bolton. 35
year old woman requesting laser removal of coarse
hair on the face and chest. No further clinical
information provided.
– Information: GP approached for:
• Evidence of underlying endocrinological/other problem e.g.
PCOS or drug side-effect
• Evidence of pharmacological interventions fully explored:
– OTC preparations
– Dianette
– Vaniqua
Case Study (2)
• Letter received from Laserase Clinic in Bolton. 35
year old woman requesting laser removal of coarse
hair on the face and chest. No further clinical
information provided.
– Information: GP approached for:
• Evidence of underlying endocrinological/other problem e.g.
PCOS or drug side-effect
• Evidence of pharmacological interventions fully explored:
– OTC preparations
– Dianette
– Vaniqua
• If treatment agreed, face only and limited treatment (policy)
Case Study (3)
• Male patient, 17 yrs old, weight, 75kg with severe
Crohn’s disease requiring anti-TNF (fits criteria).
• Recommended treatment is infliximab for patients
under 18yrs of age.
• Infliximab tried but generated allergic reaction
(shortness of breath)
• Request for funding for adalimumab, starting dose
of 160mg week, 80mg week 2, then 40mg alternate
weeks thereafter, based on clinical trial data.
Case Study (3)
• Issues?
– Licensing of drug - age of patient
Case Study (3)
• Issues?
– Licensing of drug - age of patient
– NICE guidance – age and initiation dosage
Case Study (3) contd.
• Issues?
– Licensing of drug - age of patient
– NICE guidance – age and initiation dosage
• Outcome
– Need for anti-TNF established (criteria)
Case Study (3) contd.
• Issues?
– Licensing of drug - age of patient
– NICE guidance – age and initiation dosage
• Outcome
– Need for anti-TNF established (criteria)
– Age and weight – close to “adult”
Case Study (3)
• Issues?
– Licensing of drug - age of patient
– NICE guidance – age and initiation dosage
• Outcome
– Need for anti-TNF established (criteria)
– Age and weight – close to “adult”
– Combination of these
funding agreed
Case Study (3)
• Issues?
– Licensing of drug - age of patient
– NICE guidance – age and initiation dosage
• Outcome
– Need for anti-TNF established (criteria)
– Age and weight – close to “adult”
– Combination of these
funding agreed
• BUT
– initiation dose determined as clinically appropriate by
clinician
The future...
• GM Cluster: options considered and ‘hub-andspoke’ model adopted – local policies remain
– Allows co-ordinated response to new treatments as they
arise – consistency going forward
– Model agreed but mechanism to co-ordinate effectively
still on drawing board...
• Clinical Commissioning Groups: how do they play
into this work?
– Level of involvement?
• Resilience issues – closer working with
neighbour(s)?
Summary/Key Notes
• Panel should only be dealing with exceptional/individual
cases
• Importance of clinical information – preferably upfront, but
also in response to requests from Panel. Reducing delay
reduces patient frustration!
• Direct the patient to the policy. I am happy to provide further
interpretation to GPs or patients.
Thank you!
Questions?