Embed Size (px)
Citation preview
Page 1 of 13
Individual Funding Requests Walsall CCG
Annual Report
1 April 2015 – 31 March 2016
Page 2 of 13
Add
IFR Summary for Walsall CCG
Annual Report – 1 April 2015 – 31 March 2016
1. Overview
Individual Funding Requests (IFRs) are requests to fund drugs, treatments, procedures and interventions that fall outside of the current commissioning contracts, where there is no Commissioning Policy, or when a patient does not meet the criteria within an agreed Commissioning Policy. In March 2013, Walsall Clinical Commissioning Group (CCG) adopted the Collaborative Commissioning Policy - Individual Funding Requests (IFRs). This policy provides a national and legal framework to process IFRs for patients across 7 Clinical Commissioning Groups (CCGs) including Birmingham, Solihull and the Black Country and is supported by 10 generic policies. This policy is currently being reviewed in collaboration with the 7 CCGs. In addition to the IFR and generic policies, during 2015-2016 criteria based requests are reviewed against;
NHS Black Country Cluster Aesthetic Procedures Guideline and Commissioning Policy - 2012
NHS Black Country Cluster Procedures of Limited Clinical Priority Commissioning Policy - 2012 Walsall CCG also has commissioning policies for:
Assisted Conception; and
Gamete Retrieval and Cryopreservation
Intra-Hair Lace System - 2015
The Assisted Conception Policy was implemented December 2014. Following a procurement exercise across the West Midlands, the Assisted Conception Service is now provided by Birmingham Women’s Hospital for all West Midland CCG’s. From 1 April 2016, the IFR Service transferred to Arden and Greater East Midlands Commissioning Support Unit (Arden & GEM CSU, please note the contents of this report and IFR Service Delivery was undertaken by Midlands and Lancashire Commissioning Support Unit (M&LCSU) during this period.
2. Summary of Total Number of Requests Received for 2015/16 As previously outlined, Individual Funding Requests (IFRs) are requests to fund drugs, treatments, procedures and interventions that fall outside of the current commissioning contracts, where there is no Commissioning Policy, or when a patient does not meet the criteria within an agreed Commissioning Policy. However, the term IFR can cause some confusion, for clarity; IFR is an ‘umbrella’ term which is used for:
Individual Funding Requests (IFR’s)
NICE Requests (which are criteria based)
Criteria Based Requests (assessed against specified Commissioning Policies)
Out-of-Area Patient Transport
Prior Approvals (for all provider Trusts excluding Walsall NHS Trust)
Page 3 of 13
Every request has the potential to be a ‘true’ IFR and meet the definition of ‘clinical exceptionality’. The IFR Team receives a variety of requests, often because GP’s and/or Provider Trusts are uncertain of whom to approach for funding. These can include any treatment/intervention that falls outside the Walsall CCG commissioned contracts, some of which may be commissioned by NHS England. The request may be for a standard NHS treatment with a HRG code, however, Walsall CCG does not have a contract in place with that specific provider and therefore the request is forwarded to the IFR Team. The IFR Team processes every request following the IFR route, thus reducing the risk of legal challenge. During the period of 1 April 2015 to 31 March 2016, the IFR Team processed 132 applications on behalf of Walsall CCG: All Cases Broken Down by Type of Request and Funding Decision (132 cases) - 2015/2016
* Criteria Based requests include treatments for NICE drugs
A breakdown of the treatments requested for all cases is outlined in Appendix 1.1 and a further breakdown is outlined in Appendix 1.2. A breakdown of the treatment requested for drug treatment cases is outlined in Appendix 2. There were 30 such cases and this represents 23% of the total number of cases received. Non-Drug Treatment requests accounted for 102 out of 132, this represents 77% of the total number of cases (see Appendix 3). Appendix 4 demonstrates the top 3 providers of cases that have been approved either by the IFR Screening Panel or Full IFR Panel. Appendix 5 indicates the top 3 providers for total treatment costs. Appendix 6 provides a breakdown of all approved cases that have been processed by the CSU, indicating the provider, the type of request, treatment requests and the cost of treatment. On 1 occasion the cost was not provided however this is highlighted as PBR Tariff. Appendix 7 provides a breakdown of costs for IFR and criteria based applications that were approved.
Request Type Approved Declined Pending Grand Total
Criteria Based* 39 70 4 113
IFR 6 11 2 19
Grand Total 45 81 6 132
Funding Decision
Page 4 of 13
3. Comparison Data
During the period of 1 April 2015 to 31 March 2016, the IFR Team processed 132 applications on behalf of Walsall CCG:
Request Received Approved Declined Pending Grand Total
Criteria Based 39 70 4 113
IFR 6 11 2 19
TOTAL 45 81 6 132
During the last financial period of 1 April 2014 to March 2015, the IFR Team processed 125 applications and during the period of 1 April 2013 to 31 March 2014, the IFR Team processed 165 applications on behalf of Walsall CCG. From 1 April 2016, Arden and GEM CSU took over the processing of cases for Walsall CCG: 2014-2015
Request Received Approved Declined Pending Grand Total
Criteria Based 48 38 0 86
IFR 12 23 4 39
TOTAL 60 61 4 125
* Criteria Based requests include treatments for NICE drugs
2013-2014
Request Received Approved Closed Declined Total
Criteria Based 10 22 35 67
IFR 46 7 25 78
NICE 19 1 0 20
TOTAL 75 30 60 165
This shows a steady decrease in the number of IFR cases being received year on year. (78 in 2013/14, 39 in 2014/15 and 19 in 2015/16)
3.1 Comparison of Activity Data Overall, the total number of cases processed via the IFR Team steadily decreased in 2014-2015 and 2015-2016 compared to the financial period 2013-2014. The total number of approved cases also decreased from 60 to 45 (34%) between 2014-2015 and 2015-2016. Criteria Based In comparison to the total number of criteria based requests received for 2014/15 to 2015/16 there has been an increase via the IFR Team from 86 (includes criteria based and NICE requests) to 113 which indicates a 31% increase of the total number of requests received in the given financial period. IFR In comparison between the total number of requests submitted as IFR’s from 2014/15 to 2015/16, we can see that there has been decrease in the number of IFR’s received from 39 to 19 (51% reduction). There is also a significant decrease in the number of IFR requests approved compared to the financial period 2013-2014 (56% of IFR cases approved in 2013/14, 30% approved in 2014/15 and 32% approved in 2015/16). Many requests are screened/declined at an early stage. This means of those remaining, we would expect them to go through the whole IFR process, but this is often not the case. As more information becomes available relating to the case, many cases will not reach full IFR Panel stage.
Page 5 of 13
In 2014/15, of the 19 requests received 1 progressed to the Full IFR Panel as outlined within the policy, however, this case was not approved as the IFR Panel unanimously agreed that treatment cannot be provided when it is deemed ‘Experimental and Unproven Treatment’ and ‘Rarity of itself is not a basis for agreeing an exception’. In each case there should be evidence that supports the argument that the experimental treatment might work’ (Collaborative Commissioning Policy – Individual Funding Requests, March 2014). It was noted that in 2013/14 a number of procedures were transferred to specialised services at NHS England, including Bariatric Surgery, Gender Dysphoria, Ear Surgery and Pre-Genetic Disorder (PGD) and many more. As Primary and Secondary Care providers have become familiar with the responsible commissioners of these services, fewer formal requests are received by the CSU. However, the IFR Team have noted more general telephone enquiries occurring prior to GP’s submitting requests. In some cases, having followed the IFR process, treatment requests are not deemed to be IFR’s as there is no evidence of clinical exceptionality, however, the request may be clinically appropriate/cost effective for the CCG. Service Developments Walsall CCG IFR Panels did not identify any Service Developments in the given reporting period, however, the below have been identified as gaps in Commissioning/ Contracts which have been highlighted to Walsall CCG. The IFR team have worked with the Commissioners in supporting and providing interim solutions in the management of these requests and reporting on the activity:
Open MRI Scan
Orthopaedic provisions Requests Breakdown The top 2 requests were for Open MRI Scans and Laser Treatment in 2015/16. Open MRI Scans account for 12% of requests in 2015/16 and Laser treatment requests account for 8%.
4. Prior Approval Scheme
The IFR Team does not formally provide a ‘Prior Approval’ scheme for Walsall CCG. However, a small number of requests for ‘Prior Approval’ are received, these are reviewed against the appropriate Commissioning Policies (Aesthetic or PLCP) and Walsall CCG has given delegated authority to the CSU to act upon these. Applications for drugs are reviewed by the IFR Team and are assessed against NICE Technical Appraisal Guidance (TAGs). Walsall CCG has introduced ‘Blueteq’ with Walsall Health Care NHS Trust. This enables requests that meet the criteria for high cost /NICE TAG to be processed promptly. The IFR Team continues to process requests for Walsall CCG patients attending other commissioned provider Trusts for treatment and the funding decision is made by Walsall CCG’s in-house Medicines Team.
The IFR Screening Panels are scheduled weekly and membership for the processing of IFR’s comprises of an IFR Manager (CSU), a Public Health Consultant (Local Authority/CCG) and a Senior Pharmacist from Medicines Management or GP (CCG). Minimum quoracy for decision making is a Senior Pharmacist or a Public Health representative and an IFR Manager. Walsall CCG has also requested for a members of the CCG to attend IFR Screening Panels and this has been recognised as beneficial as part of the decision making process.
5. IFR Panel
IFR Panels are scheduled as and when required and panel membership consists of a member of the CCG as the ‘Accountable Officer’ for the decision made by the panel. The panel includes a Consultant in Public Health (Local Authority), Head of IFR’s (CSU) and an IFR Manager (CSU), who presents the case. There should be at least one Medicines Management representative and one GP at each IFR Panel. The remit of the IFR Panel is to ensure that IFR cases have been screened and where clinical exceptionality is highlighted, the clinical evidence and cost effectiveness is discussed to enable the CCG member to reach a decision in any particular case.
Page 6 of 13
6. IFR Appeals Panel
Should an appeal be received, the role of the IFR Appeals Panel is to consider appeals against decisions taken by the CCG, ensuring decisions have been taken in accordance with the policies and processes of the CCG and CSU. The Appeal Panel can uphold the decision made by Walsall CCG or may refer the case back to IFR Panel for reconsideration with recommendations. The IFR Appeal Panel membership consists of a Lay Member/Chair of Walsall CCG, a Board Member GP from the CCG and the Director of Public Health (Local Authority). There were no formal appeals received for Walsall CCG during the period contained in this report, however many challenges/complaints are made against requests that have been declined. Each request is reviewed on an individual case basis and if required the case can may re-considered via the IFR Process. The IFR Team also supports the CCG’s complaints and Quality team for any complaints received directly by the CCG in relation to IFR requests.
7. Reasons for Approval of Treatment
Approvals for treatment are supported when a patient meets the clinical criteria outlined in a specific commissioning policy or the patient is deemed to be clinically exceptional, an example of this may be a patient who requires a Hip Replacement (PLCP). Providing the patient meets the criteria, NHS funding is approved by the CSU on behalf of the CCG. Alternatively, if a patient does not meet the specified criteria, or there is no criterion/commissioning policy in place to assess against, clinicians may submit an IFR application to demonstrate clinical exceptionality. Several IFRs were submitted in the period 2015/16, however, no cases were approved on the grounds of exceptionality in 2015/16.
8. Reasons for Refusal of Treatment
There are a variety of reasons why funding for treatment is not supported by the CCG, these include:
Patient does not meet the clinical criteria
Patient is not deemed to be clinically exceptional
Incomplete/poor application submitted from Clinician
Additional supporting information requested but not received
Lack of clinical evidence to support the request
Identified as a Service Development, when it is recognised that a cohort of patients may benefit from the treatment
Requests for treatment are commissioned by NHS England and therefore would be re-directed
9. Inappropriate Referrals We process a number of inappropriate requests, this includes instances where GP’s, find it challenging to explain to patients why they do not meet a certain criterion, or instances where it is known that NHS funding would not be supported (i.e. Laser Treatment for Hirsuitism/Abdominoplasty/Breast Augmentation). It is recognised that GP’s need to maintain a good relationship with their patients. However, each ‘inappropriate’ request (i.e. when a patient clearly does not meet the criteria) results in additional cost in many ways including referrals, out-patient appointments, administration and clinical time and may result in a poor patient experience. Once it reaches the IFR Team, each request will follow due process as outlined in the IFR Policy.
Page 7 of 13
As a direct consequence of declining funding, the CCG and CSU receive a number of complaints in the form of MP letters, FOI requests, challenges or appeals. The IFR Team have provided information in relation to 5 Freedom of Information (FOI) requests during this financial year. Whilst we acknowledge, there may be occasions when funding initially has been refused, subsequently, a change in clinical circumstances may result in the patient meeting the criteria and funding for treatment is approved via the IFR process.
10. IFR Training During 2015-16, five staff members attended IFR Training from Walsall CCG and Walsall MBC, which included legal advice on the processing of IFR applications, the attendees included; one Medicines Management representatives, a GP trainee, Public Health Programme Development and Commissioning Manager, Public Health Programme Support Officer and a Consultant in Public Health. As outlined in the ‘Collaborative Commissioning Policy for Individual Funding Requests’, an ‘Authorised Officer’ must undergo mandatory training organised by the CSU. This training covers both the legal and ethical framework for IFR decision making, the CCG’s commissioning processes and structures, the technical aspects of interpretation of clinical evidence and research and guidance in respect of the policies relevant to their decision making. IFR Training is regularly refreshed to ensure that the Authorised Officer maintains the appropriate skills and expertise to function effectively. Six representatives attended the IFR Master Class in October 2015, which is an annual refresher programme for those who have previously attended the IFR Training event.
11. Finance
All requests are recorded by the IFR Team and applications that are ‘Approved’ were relayed in quarterly reports to Walsall CCG Finance Team within 2 working days of the month end. This report recognises that the greatest IFR expenditure for Walsall CCG has been associated with non-contracted activity (NCA) for specialist neuro-rehabilitation assessments and treatment (crossing over two financial periods 2014-2015 and 2015-2016) at Christchurch Group for three individuals accounting to an approximate cost of £136,920. The IFR team have worked closely with Walsall CCG in recognising gaps in commissioning of specialised services and have supported in developing interim solutions in managing these healthcare needs. These requests have been processed via the IFR route to enable monitoring of financial activity.
12. Patient Transport
Arden & GEM CSU does not provide this service for Walsall CCG.
13. Future Reporting The CSU will continue to work with Walsall CCG to develop the IFR Annual Report and other reports to include a wider range of reporting summaries and commentaries.
Page 8 of 13
Report produced by: Individual Funding Requests (IFR) Team Arden and GEM Commissioning Support Unit Kingston House 438-450 High Street West Bromwich West Midlands B70 9LD
Page 9 of 13
Appendix 1.1
Breakdown of treatments requested for all cases (ie. 132 cases) – Summary
Appendix 1.2 Breakdown of treatments requested for all cases (ie. 132 cases) - Detail
All Types of MRI16 (12%)
Laser Treatment11 (8%)
Aflibercept5 (4%)
Cryopreservation5 (4%)
Excision5 (4%)
Tocilizumab 5 (4%)
Other85 (64%)
Walsall CCG - April to March 2015/2016Treatments Requested for all Cases Received (132 cases)
0
2
4
6
8
10
12
14
16
18
MR
I Sca
n/O
pe
n M
RI/
Up
righ
t M
RI
Lase
r Tr
eatm
ent
Afl
ibe
rcep
t
Cry
op
rese
rvat
ion
Exc
isio
n
To
ciliz
um
ab
Bo
tulin
um
To
xin
Bre
ast
Surg
ery
Car
pa
l Tu
nn
el R
ele
ase
Infe
rtili
ty T
reat
me
nt
Sle
ep s
yste
m
Ab
do
min
op
last
y/A
pro
ne
cto
my
Infl
ixim
ab
Kn
ee
Re
pla
cem
en
t
Re
hab
ilita
tio
n
Rit
uxi
ma
b
Tra
nsp
ort
Cat
arac
t Su
rger
y
Gyn
aec
om
asti
a P
roce
du
re
He
rnia
Re
pai
r
Life
Ve
st
LIN
X Pr
oce
du
re
Ort
ho
pae
dic
Fo
otw
ear
Psy
cho
logi
cal I
nte
rve
nti
on
Re
ferr
al f
or
Ass
ess
me
nt
Ace
tylc
yste
ine
Ad
alim
um
ab
An
kle
Fo
ot
Ort
ho
sis
(AF
O)
Bre
ast
Red
uct
ion
(M
am
mo
pla
sty)
Ce
rto
lizu
mab
Pe
gol
Co
lon
osc
op
y
Co
un
selli
ng
in B
SL
De
xam
eth
aso
ne
Eta
ne
rce
pt
Fert
ility
Pre
serv
ati
on
Ge
nd
er
Rea
ssig
nm
en
t
Hip
Rep
lace
men
t
Hip
Res
urf
aci
ng
Hys
tero
sco
py
Insu
lin P
um
p
Kn
ee
Surg
ery
Me
xilit
ine
Ner
ve S
tim
ula
tio
n D
evi
ce
No
n-i
nva
sive
ve
nti
lati
on
Ocr
ipla
smin
Ost
eop
ath
man
ipu
lati
on
Pe
nile
pro
sth
esis
Pin
nap
last
y
Pir
oxi
cam
Re
mo
val
Sati
vex
spra
y
Scar
Re
visi
on
SPA
RC
ass
ess
men
t
Ter
ipar
atid
e
Tra
nsf
emo
ral A
mp
uta
tio
n
Tri
gger
Fin
ger
Re
lea
se
Nu
mb
er
of
Cas
es
Treatment Requested
Walsall CCG - April to March 2015/2016Full Breakdown of Treatments Requested for all Cases Received (132 cases)
Pending
Declined
Approved
Page 10 of 13
Appendix 2 Breakdown of drug treatment requests (ie. 30 cases)
Appendix 3 Breakdown of non-drug treatment requests (ie. 102 cases)
Appendix 4
0
1
2
3
4
5
6
Nu
mb
er
of
Cas
es
Type of Drug Request
Walsall CCG - April to March 2015/2016Breakdown of Drug Treatment Requests Received (30 out of 132 cases)
Declined
Approved
0
2
4
6
8
10
12
14
16
18
MR
I Sca
n/O
pe
n M
RI/
Up
righ
t M
RI
Lase
r Tr
eatm
ent
Cry
op
rese
rvat
ion
Exc
isio
n
Bre
ast
Surg
ery
Car
pa
l Tu
nn
el R
ele
ase
Infe
rtili
ty T
reat
me
nt
Sle
ep s
yste
m
Ab
do
min
op
last
y/A
pro
ne
cto
my
Kn
ee
Re
pla
cem
en
t
Re
hab
ilita
tio
n
Tra
nsp
ort
Cat
arac
t Su
rger
y
Gyn
aec
om
asti
a P
roce
du
re
He
rnia
Re
pai
r
Life
Ve
st
LIN
X Pr
oce
du
re
Ort
ho
pae
dic
Fo
otw
ear
Psy
cho
logi
cal I
nte
rve
nti
on
Re
ferr
al f
or
Ass
ess
me
nt
An
kle
Fo
ot
Ort
ho
sis
(AF
O)
Bre
ast
Red
uct
ion
(M
am
mo
pla
sty)
Co
lon
osc
op
y
Co
un
selli
ng
in B
SL
Fert
ility
Pre
serv
ati
on
Ge
nd
er
Rea
ssig
nm
en
t
Hip
Rep
lace
men
t
Hip
Res
urf
aci
ng
Hys
tero
sco
py
Insu
lin P
um
p
Kn
ee
Surg
ery
Ner
ve S
tim
ula
tio
n D
evi
ce
No
n-i
nva
sive
ve
nti
lati
on
Ost
eop
ath
man
ipu
lati
on
Pe
nile
pro
sth
esis
Pin
nap
last
y
Re
mo
val
Scar
Re
visi
on
SPA
RC
ass
ess
men
t
Tra
nsf
emo
ral A
mp
uta
tio
n
Tri
gger
Fin
ger
Re
lea
se
Nu
mb
er
of
Cas
es
Type of Non Drug Request
Walsall CCG - April to March 2015/2016Breakdown of Non Drug Treatment Requests Received (102 out of 132 cases)
Pending
Declined
Approved
Page 11 of 13
Top 3 Providers for Approved Cases
Appendix 5
Top 3 Providers for Total Costs (relating to approvals)
0
2
4
6
8
10
12
14
Royal Wolverhampton NHS Trust Heart of England NHS Foundation Trust University Hospitals of North Midlands NHSTrust
Nu
mb
er
of
Ap
pro
ved
Cas
es
Provider
Walsall CCG - April to March 2015/2016Top 3 Providers for Approved Cases
13
8
4
£136,920
£63,678£57,771
£0
£20,000
£40,000
£60,000
£80,000
£100,000
£120,000
£140,000
£160,000
Christchurch Group Royal Wolverhampton NHS Trust Heart of England NHS Foundation Trust
Tota
l Tr
eat
me
nt
Co
sts
Provider
Walsall CCG - April to March 2015/2016Top 3 Providers for Total Treatment Costs Relating to Approved Cases*
* Includes a case where the estimated cost has been marked as “Tariff”
Page 12 of 13
Appendix 6 Breakdown for Approved Cases relating to IFR and Criteria Based Applications
Treatment Provider Request Type Procedure/Treatment requested
Estimated Cost of
Treatment*
Number
of Cases
Birmingham Children's Hospital NHS Foundation Trust Criteria Based Acetylcysteine £904 1
Mexilitine £896 1
Piroxicam £580 1
Birmingham Children's Hospital NHS Foundation Trust Total 3
Birmingham Women's Fertility Centre Criteria Based Cryopreservation £190 1
£2,775 1
Birmingham Women's Fertility Centre Total 2
Burton Hospitals NHSFT Criteria Based MRI Scan/Open MRI/Upright MRI £228 1
Burton Hospitals NHSFT Total 1
Christchurch Group IFR Rehabilitation £31,920 1
£52,500 each 2
Christchurch Group Total 3
Dudley Group NHS Foundation Trust Criteria Based Ocriplasmin £2,500 1
Rituximab £4,191 each 2
Dudley Group NHS Foundation Trust Total 3
Heart of England NHS Foundation Trust Criteria Based Adalimumab £9,295 1
Etanercept £9,200 1
Infliximab £3,774 1
£12,584 1
MRI Scan/Open MRI/Upright MRI £228 1
Penile prosthesis £6,895 1
Teriparatide £6,500 1
Tocilizumab £9,295 1
Heart of England NHS Foundation Trust Total 8
Midland Fertility Services Criteria Based Cryopreservation £190 each 3
Midland Fertility Services Total 3
Royal Wolverhampton NHS Trust Criteria Based Aflibercept £6,048 each 4
£12,096 1
Cataract Surgery Tariff 1
Hernia Repair £3,423 1
MRI Scan/Open MRI/Upright MRI £292 1
Tocilizumab £3,473 each 2
£4,659 1
£6,270 1
IFR Life Vest £5,800 1
Royal Wolverhampton NHS Trust Total 13
Sandwell and West Birmingham Hospitals NHS Foundation Trust Criteria Based Infliximab £11,750 1
IFR Laser Treatment £708 1
Sandwell and West Birmingham Hospitals NHS Foundation Trust Total 2
SK:N Clinic Criteria Based Laser Treatment £5,353 1
SK:N Clinic Total 1
University Hospitals of North Midlands NHS Trust Criteria Based Botulinum Toxin £667 each 4
University Hospitals of North Midlands NHS Trust Total 4
Walsall Health Care NHS Trust Criteria Based Sleep system £1,193 1
IFR Sleep system £1,436 1
Walsall Health Care NHS Trust Total 2
Grand Total £298,502 45
Page 13 of 13
Appendix 7 Breakdown of Costs for Approved Cases for IFR and Criteria Based Cases
£153,638 (39 cases)
£144,864 (6 cases)
£140,000
£142,000
£144,000
£146,000
£148,000
£150,000
£152,000
£154,000
£156,000
Criteria Based IFR
Tota
l Tr
eat
me
nt
Co
sts
Type of Request
Walsall CCG - April to March 2015/2016Costs for Approved Cases (£298,502 for 45 cases)*
* Includes a case where the estimated cost has been marked as “Tariff”
