Individual Funding Requests 1

Individual Funding Requests 1

Individual Funding Requests 2 Individual Funding Requests End of Year Report 2014/15

Individual Funding Requests 3 Background All Clinical Commissioning Groups (CCG) are required to publish a list of interventions that are not normally funded by the NHS locally. Typically, these will be procedures where there is more limited evidence of clinical or cost effectiveness, or are deemed of lower priority for local resources. A local process is required to ensure that individual clinical and / or personal circumstances can be fully considered where a clinician supports an application being put forward for funding outside of the locally agreed commissioning policy on the basis of exceptional grounds. The Individual Funding Request (IFR) Panels were established to deal with requests for funding for individual patients requesting a procedure that is not normally funded by the NHS locally. The IFR Panels are permanent sub-groups of the separate Clinical Commissioning Group Boards. The Panels support the process which has been established to ensure that applications to the Commissioners for funding of Interventions Not Normally Funded (INNF) are considered by a fair and consistent method that is open to scrutiny. The Panels are accountable through the Chairs of the IFR Panel to the Board of the Clinical Commissioning Groups. During 2014/15, South West Commissioning Support (SWCS) was been commissioned by CCGs across Bristol, North Somerset, Somerset and South Gloucestershire (BNSSSG) to provide the IFR service (see Service Level Agreement proposed but not adopted due to Lead Provider Framework process for 2014/15 at Appendix 1). Panel Membership Throughout 2014/15, SWCS worked to align the make-up of the INNF Lists and the IFR Panels across BNSSSG CCGs. CCG Boards across BNSSSG agreed the following structure. Two General Practitioners (one of whom will act as Chair) Public Health Representative Lay Member of the Clinical Commissioning Group Board Commissioning Representative (representative from Clinical Commissioning Group or South West Commissioning Support) Medicines Management Representative Administrative Support (non-voting provided by SWCS)

Individual Funding Requests 4 CONTENTS Background 3 Activity Report 5 Prior Approval Requests 5 Individual Funding Requests 5 Individual Funding Request Appeals 7 Financial Summary 8 Key Performance Indicators 9 Other 9 INNF List 9 NHS England 9 IFR Database 9 Clinical Policy Review Group 10 Criteria Based Access Audit 11 Non-Approved Activity Challenges 12 Training 13 Conclusion 13

Individual Funding Requests 5 Activity Report Each year the IFR Team process a significant number of applications for both prior approval (PA) and Individual Funding Requests (IFR). Please see the charts below for a breakdown of the numbers received, and the most common intervention types requested. Prior Approval Requests Applications Received The last three years have seen a significant decrease year on year of prior approval requests (see chart on right). This demonstrates increasing compliance with the policies on the Interventions Not Normally Funded (INNF) list by referring clinicians. As a result of this increasing compliance some referrals, including hernia referrals, are now criteria based access. 1626 1487 1138 2012-13 2013-14 2014-15 PRIOR APPROVALS RECEIVED The chart on the right shows the volume of prior approval requests received in North Somerset in the most common categories for applications. The categories differ from last year in that varicose veins surgery applications have become a larger percentage of the overall total, with hernia applications showing significant decrease and treatment for haemorrhoids also decreased. BSL 105 219 207 106 Varicose veins Individual Funding Requests Tonsillectomy Hernia Applications Received IFR applications fell during this financial year, as demonstrated by the chart on the right. This reduction was in part due to some specialist treatments now being the responsibility of NHS England to commission. However, some interventions will be moving from NHSE to CCG (Individual Funding) at the end of the next financial year. Also there will be additional policies for interventions being subject to Individual Funding Approval being incorporated throughout BNSSG and Somerset within the next financial year. 347 306 247 2012-13 2013-14 2014-15 IFR APPLICATIONS RECEIVED BSL 53 For these reasons we expect the trend to increase in the coming years Varicose Veins 14 Tonsillectomy 15 26 Nasal surgery

Individual Funding Requests 6 Many of the policies subject to Individual Funding, Prior Approval and Criteria Based Access are being reviewed during the course of the next financial year and will be brought to CPPRG for agreement and discussion prior to being submitted for Board approval. This will, in all likelihood, increase the number of applications for Prior Approval and Individual Funding, resulting in show an increase in both areas during the next 12 24 months.. In addition, across BNSSG and Somerset, all policies are being reviewed and brought into line with each other so the postcode lottery will longer be an issue for patients in the region and equity of treatment will apply. It has also been revealed that applications for treatments for toe and foot conditions are minimal which is in sharp contrast to others CCGs in our area. As a result, we are investigating how North Somerset patients are being treated for these conditions without prior approval applications. Many of the policies being reviewed with the following being amalgamated and criteria being made more comprehensive for interventions: Breast Surgery for both male and female one policy will now cover all interventions for each of these. Toe and Foot Treatments There will be a number of new policies for both Prior Approval and Criteria Based Access produced over the next 12 months which will be common across BNSSG and Somerset. These will include: Adults Tonsillectomy Policy Tonsillar Crypts Adenoidectomy Congenital Abnormality CPAP for Sleep Apnoea outside TAG Penile Prosthesis and Erectile Dysfunction Knee Arthroscopy Acupuncture

Individual Funding Requests 7 Individual Funding Request Appeals Appeals Received and Granted 11 appeals requested 11 appeals declined through screening process 0 appeals granted and in progress 0 IFR decisions upheld 4 IFR decisions overturned* *The IFR Panel decisions overturned related to decisions by Panel in 2013/14 for breast reduction surgery for gynaecomastia. The Appeal Panel considered that, as in all four cases, gynaecomastia had been graded at Band 4, this was a standard for exceptionality to be applicable. However, it has since been determined that there is not a recognized clinical banding system for gynaecomastia, the policy has now been reviewed to include this evidence and this decision should not set a precedent for the future.

Individual Funding Requests 8 Financial Summary Prior Approvals and Criteria Based Access Interventions Across BNSSG and Somerset, a total of 442 prior approval and criteria based access interventions undertaken by North Bristol Trust were challenged by IFR Team. This was for a total cost of 946,804. A new audit regime, together with a contract to undertake audits within WAHT, is being implemented during the next financial year. This is expected to both improve compliance and reduce overall spend as the results realise financial reimbursement for CCGs. The introduction of new policies for prior approval, criteria based access and individual funding will result in an increase in number of applications and costs over the next two financial years. However, this will be compensated for by the enhanced efficiency of monitoring and audit processes by IFR Team, which will enable increased transparency, effective clinical outcomes and cost efficiency savings for all CCGs across the region. Individual Funding Expenditure during the financial year was 43,900 against a budget of 60,000. This does reflect a lower spend across the region than the previous year, which can be attributed to: specialist and high cost treatments now being the responsibility of NHS England to commission Some individual funding request drugs cases approved by the Panel have also been coded to Acute Trust Activity However, spend is expected to rise over the next 24 months as: specialist and high cost treatments such as bariatric surgery will move to CCG responsibility from April 2016 the number of interventions subject to individual funding requests will rise with the introduction of new policies interventions subject to prior approval may become subject to individual funding requests This rise will be reflected in reduced costs for the budgets from which these interventions have been moved.

Individual Funding Requests 9 Key Performance Indicators A monthly Key Performance Indicator (KPI) report for each CCG is produced. This identifies trends in referrals both by intervention and by GP practice. The data is reviewed by IFR Managers prior to disseminating the information and subsequently by CCG IFR Leads. The end of year KPI report for North Somerset CCG is attached at appendix 2. The KPI report has been re-drafted for 2015/16 following CCG feedback, and will become a more comprehensive reporting tool, encompassing amended KPIs which relate to the most recently drafted service specification, and more detailed information on audits, trust challenges and policy development, whilst retaining the level of detail of the current report. Other INNF List During 2014/15 the INNF list has been updated following feedback making the list more user friendly, allowing easier navigation for referrers. As the policies are now widely consistent across BNSSG, one shared column is now in place for users to click on the policy link, therefore making the INNF list more user friendly. Policies which differ across BNSSG are listed in a short section at the bottom of the list. The updated list has been further condensed following removal of interventions commissioned by NHS England. Each intervention is listed alphabetically and all medicines have been removed and have been replaced with a link to the Bristol, North Somerset and South Gloucestershire (BNSSG) joint formulary. Please see the most recent INNF List in Appendix 3. NHS England As of 1 April 2013 there were some changes within commissioning responsibilities for NHS specialist services. This led to some confusion for providers and clinicians as to which part of the pathway in some of the specialties the commissioning responsibilities fall. The SWCS IFR Team was involved in weekly and subsequently monthly meetings with NHS England during 2013/14 to discuss queries that arose. Regular meetings are no longer in place due to fewer queries arising, however the IFR Team retained links in 2014/15 with colleagues in NHS England to ensure prompt resolution of queries regarding the responsible commissioner of certain interventions. IFR Database The IFR database is used to log all requests for funding, provides an audit trail, and can generate template letters to referring clinicians and patients. The database has provided a

Individual Funding Requests 10 significant time saving for administrative staff, and has enabled processing of a large volume of applications, whilst retaining the same levels of staffing resource. In late 2013, the IFR team were advised that to ensure sustainability, application enhancement, and improved functionality, it was recommended to commission the design of a new database. The IFR Team agreed and made specific requests for inclusion on the new database, including improved functionality to enable IFR staff to make simple changes to letter templates and drop down lists. The IFR Team worked closely throughout 2014 with the SWCS Product Solutions developers on the functionality requirements of the new system, and in March 2015, SWCS launched a newly designed bespoke Individual Funding Request Management System. The new system built on the success and effectiveness of the previous database. Improvements for the IFR Team and customers have included: Due to the new type of platform hosting the database, future enhancements can be made more quickly and easily Creation of a Central Data Repository (CDR) which holds contents of all drop-down lists, calendars etc. and is editable by the IFR Team A more modern, faster and more user friendly database Letter templates are now stored on the system and can be updated by the IFR Team Increased reporting detail Electronic signatures Staff script for telephone queries System is now compatible with multiple devices such as laptops and ipads Work is ongoing to improve the system, and further upgrades are planned during 2015/16. Clinical Policy Review Group The Clinical Policy Review Group (CPRG) is a group that reviews and develops commissioning policies across BNSSG. It primarily deals with interventions not normally funded (INNF). The group consists of senior representatives from various organisations. Membership is drawn from the CCGs, provider Trusts, Public Health and lay members. The group was set up to replace the Commissioning Advisory Forum. Commissioning decisions around drugs are now dealt with by the BNSSG Joint Formulary Group. There is no longer a separate New Interventions group as this was agreed to be tagged onto the end of the current CPRG meetings.

Individual Funding Requests 11 There are currently 80 policies relating to INNFs, ranging from fertility to tonsillectomy. The IFR team also develops new policies and has identified 25 new policies at the current time with the intention of increasing the number of policies where appropriate. The focus is on procedures where there is limited evidence of effectiveness within the wider context of capacity and resource restrictions. Progress to date CPRG met 4 times in 2014/15 and attendance and engagement has been positive. There is an updated work plan which tracks existing policies due for review, potential new policies and clinical leads across primary and secondary care, and Public Health. Policy development and review is an ongoing process between meetings and is coordinated and carried out by the IFR teams in the CSU. Clinical discussion takes place via email, telephone and face to face meetings. It has been agreed that the majority of the 124 INNF policies will be returned to the CPRG for review/ update and development in 2015. The IFR team has developed an improved policy template which enables greater clarity surrounding the policy. CPRG have given positive feedback to the adoption of the new policy template. All BNSSG IFR Managers have benefited from a Public Health training day which has helped to strengthen the teams skills set in researching evidence for support of policy development. Equality Impact Assessments (EIAs) are developed by the IFR team for each policy adopted. Approval and adoption by CCGs CPRG makes decisions about policies and then recommends them to CCG Boards for approval and adoption. The IFR teams prepare and submit the Board papers, policy and equality impact assessments. Once approval is given, the new policies are incorporated into the Trust contracts and the operational processes of the IFR service. All policy information is published on the INNF section of each CCG s website and this is updated by the IFR Team, following any board approvals. Criteria Based Access Audit Summary The Interventions Not Normally Funded (INNF) List contains a number of policies which are categorised as Criteria Based Access. The Criteria Based Access (CBA) policies allow primary and secondary care clinicians to assess their patients against the criteria which have been agreed by the Clinical Commissioning Group Boards without seeking prior approval and refer/treat patients where they feel there is sufficient evidence to support the criteria have been met.

Individual Funding Requests 12 There are no Prior Approval requirements for these policies, and therefore these policies are retrospectively audited on a regular basis, in order to obtain data by the year end to understand compliance with these policies, and where appropriate to challenge any noncompliant cases with the Providers. These were identified as the following: Cataracts Laparoscopic Cholecystectomy - Gallbladder Hip Replacement Surgery Hysterectomy for Menorrhagia Knee Arthroscopy Mirena Coils in Secondary Care Spinal and Back Pain Injections We also identified Insertion of Testicular Prosthesis as a policy due for audit but no cases were supplied on the day from the Trust at the time request due to low numbers. This will continue to be rolled over and requested for audit at each audit session until we have sufficient cases numbers to satisfy an audit. Learning Points The SWCS IFR team successfully secured clinical engagement from GPs which enhanced the validation of the audit as well as providing GPs with an improved understanding of the Individual Funding Process. An internal audit/ review of the coding in place associated with each policy to further improve the sampling of the case files audited. The audits identified a need for the SWCS IFR team to further develop relationships with secondary care to assist with their full adoption of all aspects of the policy. Improve awareness of the policies in general Future Plans To undertake CBA Audits of the Fertility Service in June 2015 To widen scope of CBA Audits to include AQP and ISTC s late 2015 moving in to 2016. To continue to improve the level of engagement from Secondary Care clinicians to enable any queries to be resolved in a timely manner. To undertake audits at WAHT Audits were undertaken at University Hospitals Bristol (UHB) in March 2015 audit report in Appendix 4a. Audits were undertaken at North Bristol Trust (NBT) in April 2015 the report is currently pending some additional information from the provider. Non-Approved Activity Challenges For the BNSSG CCG s, where there is either a prior approval policy in place or a do not commission policy, the activity that has been undertaken under these codes is reviewed

Individual Funding Requests 13 against the approvals for funding (data matching using the NHS number). Where non approved activity is identified this is challenged on a monthly basis with each of the providers. A refund for activity that has occurred but did not have approval is sought from each of the relevant providers on a monthly basis. This function leads to the delivery of allocative efficiency QIPP savings as activities of low clinical value are reduced and non-compliant activity is challenged. This resulted in significant cashable savings in previous years. SWCS has an effective system for monitoring compliance with all three categories of Clinical Commissioning Policy: All PA and IFR policies are monitored on a monthly basis. The contract activity data set is matched to the IFR database of approved cases; this check identifies all activity that has been undertaken without approval in place. All activity without approval in place is challenged back to the providers and refunds are sought. The challenges and refunds are monitored monthly via FIG. This process has improved compliance with INNF policies by acute trusts. A summary of challenges made to providers is included at appendix 5. There is no data available at this stage regarding volumes of refunds received from the providers. Training Customer Service Training The whole IFR Team undertook customer service training in early 2014 entitled Achieving Customer Service Excellence. The training built on existing customer service skills within the team, and focused on telephone techniques and customer problem solving. The training needs of both the IFR Team and the IFR Panel members are constantly monitored and assessed, and training is provided when appropriate. Conclusion IFR provision in 2014/2015 has seen significant progress in North Somerset which has been reinforced by positive customer feedback. We have seen success and progress in many areas as identified above, and continuing development of strong relationships with our CCG customers. New systems for monitoring, electronic filing and IFR processes have been introduced within North Somerset IFR during the year. This has resulted in efficiency savings, enhanced customer service and satisfaction and common practice throughout BNSSG and Somerset for all IFR Teams. IFR Panel and CCG for North Somerset have an expectation of: a caseload in the region of 25 cases to consider each month

Individual Funding Requests 14 Panel data to be available 1 week prior to Panel Panel outcomes notified within 5 working days Deferred cases monitored and reported back to Panel No backlog of cases Clinically urgent cases completed within 5 working days Invoices checked and forwarded for payment within 2 working days of receipt by IFR manager All these outcomes have been met and customer satisfaction with the service provided by CSU is high and has been reflected in the scoring and comments included in the Delivery Director Reports during the year. IFR teams across BNSSSG will continue to seek to improve and develop the service into 2015/2016, in line with customer needs and requests. Appendices: Appendix 1 SWCS IFR Service Specification Appendix 2 KPI Report Month 12 Appendix 3 Current INNF List April 2015 Appendix 4 UHB Clinical Audit Board Report Appendix 5 Non-approved activity challenge summary Appendix 6 Equalities Summary Prepared by Paul Freeman, Individual Funding Request Manager (South Gloucestershire) and Fiona Lambert, Individual Funding Request Manager (North Somerset) South, Central and West Commissioning Support Unit