Midlands and Lancashire CSU Kingston House, 438-450 High Street West Bromwich B70 9LD

www.midlandsandlancashire csu.nhs.uk

Individual Funding Requests

Birmingham South Central CCG Annual Report

1 April 2013 – 31 March 2014

IFR Summary for Birmingham South Central CCG Annual Report – 1 April 2013 – 31 March 2014

Central Midlands Commissioning Support Unit (CMCSU) was commissioned by Birmingham South Central CCG to process all applications for funding through the Individual Funding Requests (IFR) and Prior Approvals (PA) process.

“The individual funding request process is the means by which the CCG takes into account and prioritises requests for individuals with unusual clinical circumstances, which cannot be accommodated through its other commissioning processes. Being part of the CCG’s priority setting processes, the decisions taken by the IFR Panel must be guided by the same principles as priority setting in the rest of the organisation. These are set out in the CCG’s Ethical framework for priority setting and resource allocation document. These principles include taking affordability and relative priority vis-à-vis other needs into account.” IFR Policy

Prior Approvals are requests for funding that are assessed against pre-determined clinical criteria; these can be Procedures of Limited Clinical Value (PLCV), which are assessed against CCG Clinical Commissioning Policies, or applications for drugs, which are assessed against NICE Technical Appraisal Guidance (TAGs) During the period from 01 April 2013 to 31 March 2014, the CSU processed 407 applications on behalf of the CCG.

Approved Closed / Withdrawn Declined Total

IFR 8 12 7 27

Criteria Based* 286 10 57 353

NICE 23 2 1 26

NHSE 0 1 0 1

TOTAL 317 25 65 407

*criteria based requests include PLCV, Aesthetics, IVF and any other treatment that falls into a commissioned

policy.

IFR Screening Panel These panels are held weekly and membership comprises of an IFR Manager (CMCSU), a Public Health Consultant (Local Authority) and a Senior Pharmacist (CCG or CMCSU). The CCG has delegated authority that the IFR Screening Panel can made decisions against policy on all requests that are presented to IFR Screening Panel. For any cases where there is no specific clinical commissioning policy approved by the CCG, or NICE TAG, the IFR Screening Panel will review the cases to determine whether exceptionality could be demonstrated from the information provided by the referring clinician. They will also review to determine additional information that may be required to make a fully informed decision on funding prior to referring the case to the Full IFR Panel. 20 cases were reviewed by the IFR Screening Panel during the period of this report:

Month 13/14 Approved Closed Declined Total

Apr-13 0 0 1 1

May-13 1* 0 3 4

Jun-13 2 0 1** 3

Jul-13 1** 0 1 2

Aug-13 0 0 3 3

Sep-13 0 0 0 0

Oct-13 0 0 1 1

Nov-13 0 0 0 0

Dec-13 0 0 1 1

Jan-14 1** 0 0 1

Feb-14 0 1 2 3

Mar-14 0 0 1 1

** - cases also reviewed at Full Panel * N.B. The date is when the application was originally submitted and not the date of the panel meeting.

0

1

2

3

4

5

Ap

r-1

3

Ma

y-1

3

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

De

c-13

Jan

-14

Feb

-14

Ma

r-14

Nu

mb

er

of

app

licat

ion

s

Month

Outcomes of the applications reviewed at IFR Screening panel by Month

Closed

Declined

Approved

Full IFR Panel The Full IFR Panel is scheduled monthly and panel membership contains at least one member of the CCG as the ‘accountable officer’ for the decision made by the panel. The panel consists of a Senior Pharmacist (CCG or CMCSU), a GP (CCG), a Consultant in Public Health (Local Authority), Head of IFR’s (CMCSU) and an IFR Case Manager. Their remit is to consider IFR cases that have been screened and where clinical exceptionality is highlighted, the clinical evidence and cost effectiveness is discussed to enable the Clinical Commissioning Group member to reach a decision in any particular case. 4 cases were referred to a Full IFR Panel for a decision; three cases were approved and one case declined.

IFR Appeals Panel Should an appeal be received, the role of the IFR Appeal 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 CMCSU. The appeal panel can uphold the decision made by Birmingham South Central 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 Birmingham South Central CCG, a Board Member GP from the CCG and the Director of Public Health (Local Authority). No formal appeals have been received for Birmingham South Central CCG cases during the period contained within this report. 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 carpal tunnel surgery (Procedure of Limited Clinical Value). Providing they meet the criteria, NHS funding is approved. Alternatively, if a patient does not meet the specified criteria, or there are no criteria or commissioning policy in place to assess against, clinicians may apply on the grounds of exceptionality. An example of this type of request

was for a Diaport machine for a patient with uncontrollable diabetes. Funding was approved as the patient was deemed to be clinically exceptional as there were no other patients identified in South Birmingham CCG, or surrounding areas, with the same clinical condition and circumstances. Reasons for Refusal of Treatment There are a variety of reasons why funding is not supported and these include:

• Patient does not meet the clinical criteria.

• Patient is not deemed to be clinically exceptional.

• Incomplete/poor application from Clinicians.

• 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.

Decisions Made by Type of Request:

0

50

100

150

200

250

300

350

400

criteria base IFR NHS England NICE Guidance

nu

mb

er

of

app

licat

ion

s

type of request

Type of applications reviewed by IFR team

0

5

10

15

Approved closed Declined

8

12

7

IFR Applications

0

100

200

300

Approved closed Declined

nu

mb

er o

f re

qu

ests

Decision

Outcomes for the criteria base applications

0

10

20

30

Approved closed Declined

23

2 1

Outcomes for the NICE Criteria

0

0.5

1

Approved Declined Closed

0 0

1

Outcomes for the NHS England applications

criteria base, 353

NICE Guidance,

26

Criteria base applications

criteria base applications are requests that are reviewed in line with a commissiooning policy, this includes IVF, PLCV and Aesthetic

Total Applications received by procedure

Total Applications received by date The IFR team received an average of 34 cases per month.

0

5

10

15

20

25

30

35

40

45

50

Ab

do

min

opl

asty

AD

HD

Ref

erra

l

An

ti-T

NF

Trea

tmen

t

An

ti-T

NF

Trea

tmen

t

Art

hro

sco

py

of

Kn

ee jo

int

Ble

ph

aro

pla

sty

Bo

tulin

um

to

xic

Bre

ast

red

uct

ion

Bre

ast

surg

ery

Car

pal

Tu

nne

l Su

rger

y

Co

lon

osc

op

y

Co

nd

uct

ive

Edu

cati

on

D&

C

Do

nor

inse

min

atio

n

Ear

Rec

on

stru

ctio

n

Exci

sio

n o

f A

nal

Ski

n T

ags

Exci

sio

n o

f ga

ngl

ion

cys

t

Exci

sio

n o

f lip

om

a

Exci

sio

n o

f m

uco

id c

yst

Exci

sio

n o

f Se

bace

ou

s C

yst

Exci

sio

n o

f sk

in le

sio

n

Face

t Jo

int

Inje

ctio

n

Fert

ility

Pre

serv

atio

n

Flex

ible

Sig

mo

ido

sco

py

Flu

pirt

ine

Tab

lets

Gal

lsto

ne s

urg

ery

Gen

ital

su

rger

y

Gro

mm

ets

Hae

mo

rrh

oid

ecto

my

Hyp

erb

aric

Tre

atm

ent

Ingu

inal

Her

nia

Rep

air

Inse

rtio

n o

f In

sulin

Del

iver

y Po

rt

Insu

lin P

um

p a

nd

Co

nsu

mab

les

IVF/

ICSI

tre

atm

ent

Lab

iap

last

y

Lase

r H

air

Rem

ova

l

Lase

r re

surf

acin

g

Lase

r Tr

eatm

ent

Liga

men

t re

con

stru

ctio

n

Mic

ro-n

eed

ling

ther

apy

MR

-gu

ided

Fo

cuse

d U

ltra

sou

nd

MR

I sca

n

NIV

Mac

hin

e

Ort

ho

tic

Trea

tmen

t

Ozu

rdex

Tre

atm

ent

Pal

mar

Fas

ciec

tom

y

PET

sca

n

Pin

nap

last

y

Pla

stic

rem

ova

l

Rem

ova

l of

no

se p

ierc

ing

Rev

isio

n o

f sc

ar/k

elo

id

Rh

ino

pla

sty

Rit

uxi

mab

Tre

atm

ent

Sigm

oid

osc

op

y

TIL

ther

apy

Ton

sille

cto

my

Tota

l Hip

Rep

lace

men

t

Tota

l hys

tere

cto

my

Tota

l kn

ee r

epla

cem

ent

Trig

ger

fing

er s

urg

ery

Vas

cula

r Sk

in L

esio

ns

nu

mb

er

of

app

licat

ion

s

Name of procedure

Total Number of Applications by Procedure

criteria base IFR NHS England NICE Guidance

The IFR team received an average of 3 IFR applications per month:

The IFR team received an average of 2 applications for funding, for review against NICE TAGs per month:

The IFR team received an average of 29 applications for review against criteria per month:

0

10

20

30

40

50

60

Nu

mb

er o

f a

pp

lica

tio

ns

Months 2013/14

Criteria Based applications reviewed by Month

crit

eria

bas

e

IFR

NH

S En

glan

d

NIC

E G

uid

ance

Gra

nd

To

tal

Abdominoplasty 4 4

ADHD Referral 1 1

Anti-TNF Treatment 2 3 12 17

Anti-TNF Treatment 2 2

Arthroscopy of Knee joint 47 47

Blepharoplasty 1 1

Botulinum toxic 1 1

Breast reduction 1 1

Breast surgery 1 1

Carpal Tunnel Surgery 32 32

Colonoscopy 7 7

Conductive Education 1 1

D&C 3 3

Donor insemination 1 1

Ear Reconstruction 1 1

Excision of Anal Skin Tags 1 1

Excision of ganglion cyst 8 8

Excision of lipoma 4 4

Excision of mucoid cyst 1 1

Excision of Sebaceous Cyst 7 7

Excision of skin lesion 9 9

Facet Joint Injection 4 4

Fertility Preservation 1 1

Flexible Sigmoidoscopy 3 3

Flupirtine Tablets 1 1

Gallstone surgery 1 1

Genital surgery 2 2

Grommets 4 4

Haemorrhoidectomy 6 6

Hyperbaric Treatment 1 1

Inguinal Hernia Repair 19 19

Insertion of Insulin Delivery Port 2 2

Insulin Pump and Consumables 7 7

IVF/ICSI treatment 9 1 10

Labiaplasty 3 3

Laser Hair Removal 37 1 38

Laser resurfacing 4 4

Laser Treatment 13 13

Ligament reconstruction 1 1

Micro-needling therapy 2 2

MR-guided Focused Ultrasound 1 1

MRI scan 1 1

Source of Referrals

Applications for funding were received from 28 different referrers / providers, with almost 52% of the referrals being received from Highest Referrer. The top five referring organisations were:

criteria base IFR

NHS England

NICE Guidance Grand Total

BMI The Edgbaston Hospital 211 211 52%

S&WB 50 2 8 60 15%

HoEFT 39 1 13 53 13%

University Hospital Birmingham 15 9 0 1 25 6%

Laurie Pike Health Centre 11 11 3%

Sub-Total 326 12 0 22 360 89%

NIV Machine 8 8

Orthotic Treatment 1 1

Ozurdex Treatment 1 4 5

Palmar Fasciectomy 10 10

PET scan 1 1

Pinnaplasty 1 1

Plastic removal 1 1

Removal of nose piercing 1 1

Revision of scar/keloid 9 9

Rhinoplasty 5 5

Rituximab Treatment 1 1 2

Sigmoidoscopy 4 4

TIL therapy 2 2

Tonsillectomy 5 5

Total Hip Replacement 22 22

Total hysterectomy 9 1 10

Total knee replacement 35 35

Trigger finger surgery 10 10

Vascular Skin Lesions 1 1

Grand Total 353 27 1 26 407

IFR Training

During 2013-14, the IFR provided four IFR Training sessions, including legal advice on the processing of applications and one IFR Masterclass. The following BSC CCG staff attended the IFR Training programme:

Alima Batchelor Medicines Management Lead

Richard Mendelsohn GP

Waleed Doski GP

Simon Doble Commissioner

Chrissy Tate Administrator

18 attendees from Birmingham/Solihull Public Health were also trained in the IFR process. 1 CCG member and 3 Birmingham Public Health colleagues attended the IFR Masterclass, which was provided by CMCSU to provide advanced training to support the processing of complex IFR applications.

0

50

100

150

200

250

Applications Received by Referrer

criteria base IFR NHS England NICE Guidance

Report produced by: Individual Funding Requests (IFR) Team, Central Midlands Commissioning Support Unit, Kingston House, 438-450 High Street, West Bromwich, West Midlands. B70 9LD Harinder Kaur – Senior IFR Manager Terri-Ann Millington – IFR Case Manager