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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?