Paper Summary Sheet DETAILS Part 1 X Part 2 Agenda Item (Open) (Closed) 4.1 Title of Paper Individual Funding Request (IFR) Annual Report Meeting Board Meeting Date 8 September 2016 Executive Lead / Clinical Lead Dawn Clarke, Director of Nursing and Quality Dr James Hampton Author Jackie Ayres, IFR, PALS and Complaints Manager Appendices Pages 8,9 and 10 Appendices 1,2 & 3 PURPOSE Approval Discussion x Information x Assurance x EXECUTIVE SUMMARY Summary of Key To update the Board on activity from the Individual Funding Request (IFR) Points process for 2015-16. Background CCGs have a statutory responsibility to commission care, including medicines and treatments, for their populations within available resources. An Individual Funding Request (IFR) is a request to fund a healthcare intervention that falls outside the range of services and treatments that the local Clinical Commissioning Group (CCG) has agreed to commission. In 2015-16, the CCG received a total of 749 Individual Funding Request applications. This represents an increase of 8% (60 applications) when compared with the 689 applications received in 2014-15. The Clinical Priorities Policy Framework for Individual Funding Requests was updated and approved by the CCG in May 2013 to reflect the statutory requirements of NHS England, the CCG and the changed commissioning responsibilities. Further work has continued to take place on the review and update of the Clinical Policies used to assess individual funding requests. Full details of the clinical policies update in 2015-16 can be found in the main body of this report. http://www.bathandnortheastsomersetccg.nhs.uk/documents/what-we-doand-dont-fund On line IFR applications To date, there are just 5 remaining GP practices yet to sign up to the on line Blueteq system for Individual Funding Requests. Risk High Medium x Low For information, Criteria Based Access procedures cover a wide range of services including, but not limited to, varicose vein surgery, excision of ganglions, tonsillectomies and insertion of grommets (Myringotomy). A revised requirement for Criteria Based Access (CBA) procedures in all
Impact on Quality Impact on Finance local providers requires completion of a Prior Notification Form by the clinician. This form sets out how the clinician has determined that the criteria have been met for the planned treatment/procedure. This will enable the IFR team to link CBA procedures to invoice activity and will assist with the audit programme planned for late 2016 as part of the Improving Value Scheme The CCG works to evidence based criteria where available and possible to ensure patients receive high quality, effective and safe services. No concerns regarding the outcome of a decision were taken through to the Appeals Panel in 2015-2016. The total spend for all 3 funding categories; prior approval, criteria based access and exceptional funding for 2015-16 was 3,851,898. When compared with the total spend for 2014-15 of 4,241,512, a difference of 362,614 can be seen. This represents a reduction of 8%. In addition, spend on fertility services for 2015-16 is 212,358 compared with spend in 2014-15 of 305,527. A difference of 93,169 can be seen, representing a reduction of 30%. Recommendation During the creation of this report, it was identified that spend on IFR is only provided for inpatient procedures. A request for spend on IFR for outpatient procedures has been requested and the committee will be updated in due course. The Board are asked to note the contents of this report and support the planned actions within. OTHER INFORMATION Who has been Dawn Clarke, Director of Nursing and Quality involved/contributed Jackie Ayres, IFR, PALS and Complaints Manager Carol King, CSCSU Health Intelligence Advanced Analyst John Fogg, CCG Finance Lead Dr James Hampton- Clinical Lead Cross Reference to Strategic Objectives National Policy / Legislation Review Improving quality, safety and individuals experience of care Improving consistency of care and reducing variation of outcomes Reducing inequalities and social exclusions and supporting our most vulnerable groups http://www.nice.org.uk/guidance/ http://www.england.nhs.uk/wp-content/uploads/2012/12/pss-manual.pdf http://www.england.nhs.uk/.../eu-cross-border-hc-commissioners- 0614.pdf Annual Report to JCC and Board Equality & Diversity Applicable Not Applicable No significant equality or diversity issues have been identified as a result of this report. Service delivery is not being compromised. The IFR process considers any request for funding for any patient and for any treatment/intervention. Page 2 of 10
Individual Funding Request (IFR) Annual Report 2015/16 1. Executive Summary This report gives an overall picture of activity for the year 2015/16. Since the introduction of the bespoke software Blueteq in December 2013 the IFR Team has worked with the Software Company to implement continuous improvements to the system to enable accurate and comprehensive reporting. With the support of the CSU analytical team and the CCG finance team, the CCG is able to provide a thorough in depth report of funding requests and associated cost implications, instigating challenges to providers against these costs where they do not align with approved individual funding requests. Future reports will continue to improve and will contain more in depth reporting of trends. The Board is asked to note the 2015-16 year-end report and support the proposed future plans within. Purpose CCGs have a statutory responsibility to commission care, including medicines and treatments, for their populations within available resources. Decisions on whether to fund medicines and treatments should be taken in the context of the CCGs available resources and ensure that care is fairly allocated to all patients and, where appropriate, measures against the CCGs other service development priorities. The Clinical Priorities Policy Framework for Individual Funding Requests was updated and approved by the CCG in May 2013 to reflect the statutory requirements of NHS England and the CCG s commissioning responsibilities. A review and update of Clinical Policies is being undertaken on a rolling programme. To date, policies for Tonsillectomy, Ganglion, Open MRI, Hyperhidrosis (excessive sweating), Minor Foot Procedures, IVF, Pinnaplasty, Pain, Apronectomy/Abdominoplasty and Varicose Vein Surgery have all been reviewed and updated in line with NICE and/or national guidance where applicable. Presently, clinical policies are being reviewed and updated for breast surgery, minor eye procedures and benign skin lesions with a plan to review the Hernia Policy, the plastic and dermatological policy, the Ear Wax policy and the Botulinum Toxin Policy later in the year. For information, minor eye procedures, plastic and dermatological procedures and treatment/removal of benign skin lesions represent 3 of the most commonly requested procedures within the individual funding request process. The review of the clinical policy for these 3 procedures should allow for a more robust assessment against set criteria enabling a better distinction between cosmetic and clinical need. Page 3 of 10
It is worth noting that since the policies for Tonsillectomy, Ganglion and Varicose Vein procedures were reviewed in 2015 and altered from Prior Approval to Criteria Based Access, the number of procedures undertaken has reduced. In 2015-16 a total of 749 applications requesting individual funding were received. The chart below details the number of applications received by quarter. For comparison, the identical chart for 2014-15 can also be seen below. 250 200 150 100 50 Individual Funding Requests 2015-16 162 168 184 235 Series1 0 Q1 15-16 Q2 15-16 Q3 15-16 Q4 15-16 200 150 100 50 Individual Funding Requests Received 2014-15 158 172 190 169 Series1 0 Q1 14-15 Q2 14-15 Q3 14-15 Q4 14-15 The table provided at Annex 1 gives a detailed journey of all 749 IFR applications. The chart at Annex 2 details procedures broken down by numbers. The chart at Annex 3 details the procedures applied for throughout 2015-16 and the 3 most common are highlighted. These account for 58% of the total amount received. A breakdown of all 749 applications by procedure is included at Annex 3. Page 4 of 10
Funding for Blueteq is on-going and good relationships have been forged between the IFR team and the Blueteq software team. Staffing levels are currently sufficient to maintain status quo but it is worth noting a risk of a backlog occurring during periods when the team is not at full capacity. The IFR team forward plan to ensure IFR applications in the system are completed in the run up to periods of Annual Leave. Blueteq has enabled the CCG to streamline the IFR process and the team will continue to improve the operability of the system in line with the software engineers leading to more timely responses, the ability to track the progress of each request submitted and the production of detailed reports showing trends and numbers of referrals. This is a significant improvement for both patients and practices. Blueteq has a finance and invoice module that is currently being updated to ensure that the correct procedure codes align with the appropriate procedure. Work is also taking place with the RUH to ensure that procedures are being coded correctly and invoiced accordingly. Going forward, this will ensure there are no instances of double counting by providers. The utilisation of this module will ensure that all IFR authorised invoices can be linked to the Blueteq system. When the Blueteq system was first introduced, the areas for each IFR procedure were not clear and therefore a percentage of referrals were logged on to the system as uncategorised/unknown. The IFR team have now accurately linked each IFR procedure to its most appropriate specialty and the Blueteq software team are updating the system accordingly. This now allows for accurate reporting by specialty. The CCG actively challenges secondary care data for all providers if it is identified that approval prior to treatment has not been sought. By utilising the Blueteq reporting function and techniques from CSCSU, the IFR team can ensure that the CCG only pay for authorised treatment. This is now a routine collaborative process. Financial Impact The total spend for 2015/16 for Prior Approvals, Criteria Based Access and Exceptional Funding was 3,851,898. In November 2015, changes to the contract with Emerson s Green Treatment Centre for the microsuction of ear wax were implemented. These changes required the provider to align themselves with our clinical policy for microsuction which requires prior approval for treatment in a secondary care setting. Prior to the change in contract, EGTC were seeing an average of 17 patients per month for this procedure. Since 1 November 2015, this has reduced to an average of 5. Page 5 of 10
A full review of a handful of historically funded cases was undertaken in 2015-16, some of which resulted in cost savings to the CCG. The IFR team will continue to review remaining cases and update on cost savings in future reports. The total spend for all 3 funding categories for 2015-16 is detailed below alongside spend for 2014-15 for comparison purposes. Cost breakdown 2014-15 Spend 2015-16 Spend Prior Approval 258, 798 119,853 Criteria Based Access 3,745,652 3,607,536 Exceptional Funding 210,152 124,509 Total 4,214,512 3,851,858 4. Risks and Mitigating Actions There are 3 streams for funding. They are the CCG IFR, NHS England Specialist Commissioning and the European Cross border. The latter is still funded through the CCG although controlled by a central team. This added complexity means the CCG needs to be clear on what exactly it commissions. In 2015/16 the CCG received zero (0) EU cross border treatment applications. Medications for use outside of the approved Bath Clinical Area Partnership (BCAP) Formulary still come through the standard IFR route. During the creation of this report, it was identified that spend on IFR is only provided for inpatient procedures. A request for spend on IFR for outpatient procedures has been requested and the committee will be updated in due course. 5. Individual Funding Request Panel The IFR Panel meets monthly either in person or virtually (depending on quoracy and ability to attend). Significant input has been received from the Public Health Team and Medicines team and all Senior Commissioning Managers input where relevant to their workstreams. 6. Conclusion and Next Steps Currently the assumption is that providers are ensuring that patients meet the necessary criteria before carrying out any treatment or procedure that is criteria based access. The introduction of a rolling audit programme will begin in August 2016 and a team from the CCG, in conjunction with Wiltshire CCG, will make its first visit to the RUH to audit a sample of patient notes from the following 5 specialties: Cataracts Page 6 of 10
Cholecystectomy for asymptomatic Gall Stones Carpal Tunnel Tonsillectomy Varicose Veins A clinical review of these notes will determine if the criteria set by the CCG for each procedure was fully met. A challenge will be instigated for any procedure that has been undertaken despite criteria not having been met. Currently, a Prior Notification Form is being completed by some clinicians for Criteria Based Access procedures and does offer the CCG some assurance. The review and update of remaining clinical policies is ongoing. Once complete these will be uploaded to the website. Policies that do not need a full clinical update/review, are being formatted in line with CCG branding guidelines, signed off by IFR panel members and uploaded to the website. Discussions are in place with the IFR team and the referral support service (RSS) regarding the production of a revised leaner version of the Clinical Priorities Policy book for distribution to GP practices. A definition of IFR and guidance on the process is now available on the CCG website. Plans are in place to improve the link with finance to enable the tracking of funding requests against procedure codes and invoices from start to finish. Regular scrutiny of IFR invoices is ongoing and it is worth noting that on several occasions invoices have been identified as duplicate, incorrect amounts charged or not for a BaNES patient. Work will continue to encourage remaining Practices to use the on-line Blueteq Software System. An improving value scheme to audit compliance with criteria based access policies in our providers will commence in August 2016. 6. Recommendations The Board is asked to note the contents of this report and support the planned next steps with regard the improving value scheme to audit compliance with criteria based access. Page 7 of 10
Annex 1 Detailed journey of the 689 IFR applications received in 2014/15 compared with 2015/16 2014-15 2015-16 Prior Approval Approved 433 Prior Approval Approved 447 Prior Approval Declined 35 Prior Approval Declined 53 IFR Panel Approval 44 IFR Panel Approval 30 IFR Panel Declined 19 IFR Panel Declined 27 Criteria Based Access 65 Criteria Based Access 84 Administrative Closure 54 Administrative Closure 45 Further Information Required 22 Further Information Required 42 Virtual IFR Panel Approved 3 Virtual IFR Panel Approved 2 Referred to Specialist 4 Referred to Specialist 3 Commissioning/NHSE Commissioning/NHSE Pre IFR Panel decision 2 Pre IFR Panel decision 9 Application Withdrawn 3 Application Withdrawn 4 Awaiting Decision 2 Awaiting Decision 1 Referred to IFR Panel 2 2 Referred to IFR Panel 2 1 Virtual IFR Panel Decline 1 Virtual IFR Panel Decline 1 Total 689 Total 749 Page 8 of 10
Annex 2 Most commonly applied for procedures 64 38 Breast Surgery Procedures 72 110 Benign Skin Lesions Plastic Surgery Procedures 42 Minor Foot Procedures 41 115 Minor Eye Procedures Specialist Assessment/Referral 92 81 Referral to Weight Management Services Page 9 of 10
Annex 3 Breakdown of IFR applications 2015-16 Abdominoplasty/Apronectomy 4 Blephoraplasty 5 Botox (Muscular, Incontinence, Hyperhydrosis) 20 Breast Surgery Procedures 38 Benign Skin Lesions 110 Diagnostic Procedures 10 Drugs 26 Ear, Nose and Throat 72 Equipment Requests 1 Functional Electrical Stimulation 2 In-growing toenail/fingernail 3 Laser Surgery 2 MH assessment 16 Minor Eye Procedures 92 Minor Foot Procedures 81 Miscellaneous/n/a 64 Plastic and Dermatological Procedures 115 Specialist Assessment/Referral 41 Urology 5 Weight Management 42 Total 749 Page 10 of 10