Policy for Leicester, Leicestershire and Rutland Approved Referral Pathways

1 INTRODUCTION

This policy describes the clinical threshold and exclusion criteria which the Leicester, Leicestershire and Rutland (LLR) Integrated Care Board (ICB) has agreed to for planned procedures and treatments contained within this policy. Since initial ratification in 2018 the policies have been reviewed.

Please note that all red flag concerns and 2 WW pathways are excluded from this document.

The policies were previously known as Approved Referral Pathways, to avoid misinterpretation LLR ICB have taken feedback and renamed each as LLR Policies.

All reviewed policies are available @  https://leicesterleicestershireandrutland.icb.nhs.uk/your-health/healthcare-and-treatment-policies/

1.1 BACKGROUND

This policy document has been agreed to and is supported by NHS Leicester, Leicestershire and Rutland ICB

The policies aim to improve consistency of access so allowing fair and equitable planned treatment for the population of LLR. It ensures that:

• Patients receive appropriate health treatments in the right place and at the right time.
• Treatments with no or a very limited clinical evidence base are not used.

Integrated Care Boards (ICB) are responsible for commissioning healthcare services that meet the reasonable requirements of their population. This is done within an agreed financial envelope. This policy enables the ICB to prioritise its resources using the best evidence about what is clinically effective and to provide the greatest proven health gain.

1.2 PRINCIPLES

These have been made in consultation with primary and secondary care clinicians, public health and patient representatives and revised in accordance to the principles set out below, alongside the national Evidence Based Intervention policies:

• Clear evidence of clinical effectiveness.
• Clear evidence of cost effectiveness.
• The cost of treatment to the patient has been taken into account.
• The extent to which individuals or patient groups will benefit from the treatment
• Balance the needs of the individual against the benefit which could be gained by alternative investment possibilities to meet the needs of the community.
• Consider all relevant national standards an authoritative guidance.
• Where treatment is supported, it is delivered in the most appropriate clinical setting based on clinical need.

This policy summarises the planned procedures and treatments that the LLR ICB will either not fund or will fund when the patient reaches a specified clinical threshold. These thresholds were agreed in consultation with clinicians from University Hospitals Leicester (UHL) and former CCG and current ICB clinical leads.

The policies are categorised as either:

• Not routinely funded.
• Threshold Criteria.

1.3      NOT ROUTINELY FUNDED TREATMENT OR PROCEDURE

This is a group of treatments or procedures that the LLR ICB does not fund, as not having the treatment or procedure will not have a negative impact on the patient’s physical or mental wellbeing.

However, the LLR ICB will fund these treatments/ procedures in the following circumstances-

• Post- physical trauma.
• Part of a reconstruction following surgery e.g., for cancer.
• Part of the management of a congenital abnormality which results in a serious health function deficit.
• For a condition directly attributable to a previous medical treatment delivered within the NHS. This excludes known side effects of a treatment or possible complications which the patient would normally be notified of as part of the benefits and risks of the consenting processes.
•  Treatment will be funded if an Individual Funding Request (IFR) application proves there to be an exceptional clinical need, which is also supported by the ICB.

1.4      THRESHOLD CRITERIA FOR TREATMENT OR PROCEDURE

This means the LLR ICB will only fund the treatment or procedure if the patient meets the stated clinical threshold for treatment.

1.5      INDIVIDUAL FUNDING REQUEST (IFR)

There may be times where there it is clinically appropriate to fund a procedure which is NOT ROUTINELY FUNDED. The LLR ICB will consider these requests on a case-by-case basis by application to the IFR panel. Please refer to the INDIVIDUAL FUNDING REQUEST (IFR) PRISM pathway for forms and guidance.

The panel will focus on the following:

• Are there any clinical features of the patient’s case which make the patient significantly different to the general population of patients with the condition in question at the same stage of progression of the condition?
• Would the patient be likely to gain significantly more benefit from the requested intervention than might normally expected for the general population of patients with the condition at the same stage of the progression of the condition?

1.6 PRIOR APPROVAL

PRIOR APPROVAL is another check point to ensure the patient meets the threshold criteria.

This process is managed by a third party, who may ask for further information and compare the referral against the criteria of the policy.

The referral process can be found within PRISM web, all required information must accompany the referral and sent to lcr.ifr@nhs.net

A panel comprising of a Public Health Consultation, GP and Plastic Surgery Consultant meet bimonthly to review referrals with supporting evidence. The GP and patient will be notified in writing of the outcome of funding request.

Providers must ensure that PRIOR APPROVAL has been given before commencing any treatment pathway.

 1.7      EQUALITY AND QUALITY IMPACT ASSESSMENTS

 The LLR ICB has assessed the impact of the policies on the population of LLR where they have been major changes to the policies

1.8      MONITORING AND REVIEW

This policy will be subject to continued monitoring using a mix of the following approaches:

• Prior approval process.
• Individual funding requests.
• Post activity monitoring through routine EBI activity data.
• Post activity monitoring through adhoc clinical audits.

2.0 NOT ROUTINELY FUNDED

The following table lists all the LLR Approved Referral Pathways that are not
routinely funded.

3 THRESHOLD CRITERIA

The following table lists all the LLR Approved Referral Pathways that have clinical threshold criteria.