What is Clinical Prioritisation?
Clinical prioritisation is the process by which NHS Suffolk makes decisions on funding, prioritisation and disinvestments. The decisions are made by the Suffolk Clinical Priorities Group (SCPG) and cover four areas:
1. Treatment thresholds (procedures for which there is a set of criteria that need to be met before NHS Suffolk will provide funding),
2. Partially excluded procedures (procedures that will not normally be funded),
3. Funded development, and
4. Implementation of NICE guidance.
Why prioritise?
The rationale behind clinical prioritisation is to:
1. Maximise the health and well being of the population of NHS Suffolk within the limits of the resources available to us.
2. Decide on the priority that should be given to various treatments and services, and whether those treatments or services should be funded.
3. Consider existing treatments or services from which NHS Suffolk could disinvest.
How is clinical prioritisation done?
The SPCG makes clinical prioritisation decisions. The decisions made by the SCPG apply to NHS Suffolk patients being treated at any provider trust. These represent our policy and form part of the contracting process.
Suffolk Clinical Priorities Group (SCPG) - Summary Terms of Reference
The membership of SCPG is drawn from NHS Suffolk, Ipswich Hospital Trust, West Suffolk Hospital, Suffolk Mental Health Partnership Trust, primary care and the community. Nine members of the SCPG have voting rights. The group is accountable to the Board via the chair of the forum. It also reports decisions to the Professional Executive Committee (PEC). The group meets monthly and, if necessary, on ad hoc basis to deal with urgent issues.The SCPG makes funding decisions on clinical processes including new drugs, technologies and NICE guidance. The SCPG also decides on the implementation of policies that have immediate or long-term financial implications across the health economy. Decisions are made based on the following criteria:
Effectiveness: does it work and what does it achieve?
Relevance: is it relevant to our population?
Acceptability: is it acceptable to patients and clinicians?
Guideline: what is the proposed use?
Clinical and Managerial responsibility: where is the responsibility (e.g. for prescribing)?
Financial impact: what is the cost and where does it fall?
Economic appraisal: Is it worth the (extra) cost?
Priority status:How does it compare with our other priorities?
Equity: does this decrease inequity?
Financial ability: can we afford it, or how do we afford it?
The final decision on whether or not to fund a clinical process and to what level rests with the voting members. Funding requests from provider trusts should be submitted to the SCPG on a standard template which is available upon request and on the NHS Suffolk website. Cases must be submitted at least three weeks prior to the SCPG meetings.
Through the SCPG, a list of low priority procedure policies has been developed. These cover partially excluded procedures and procedures where a threshold applies.
Implementation of clinical prioritisation
The following section describes the referral process for procedures on the “Partially Excluded Procedures” and “Treatment Thresholds” list.
Partially excluded procedures:
These are procedures which are not normally funded. If a treating clinician considers that the patient requires an intervention on the partially excluded procedure list on exceptional grounds then a request has to be submitted to the PCT exceptional funding panel (EFP) using the EFP request form. Once EFP approval is received, the GP may refer the patient for treatment. The referral should include the letter from the EFP approving the partially excluded procedure.
Threshold procedures
Group Prior Approval (GPA) applies to procedures or treatments where thresholds apply i.e. threshold (T) policies on the low priority rocedures list. If a GP deems it appropriate to refer a patient for a procedure for which treatment thresholds apply, the GP can refer the patient for treatment. The referral must specify that the patient meets the PCT threshold. The consultant accepting the patient also has to ascertain that the patient meets the PCT threshold. If a GP is unsure about whether or not treatment is required, he/she may refer the patient to a consultant for consideration. The consultant will then review the case against set criteria. If the patient meets the criteria and a threshold procedure is required, the consultant will accept the patient for treatment. If the patient does not require any further treatment, he/she should be referred back to the GP for appropriate management in primary care. If the GP still considers a threshold procedure necessary, and the patient does not meet the PCT threshold, the GP should request approval for treatment through the EFP and refer the patient to the consultant once approval (IPA) is obtained.
The referring GP has criteria available for use before referral. The consultant seeing the patient needs to complete the PCT form outlining the eligibility criteria for threshold procedures, which will then be filed in the patient’s notes.
Monitoring
The Primary Care Trust will monitor the adherence to the low priority procedures policies as follows:
Partially excluded procedures.
As mentioned above, these procedures are not normally funded. The PCT has identified a series of OPCS codes (Office of Population, Censuses and Surveys: Classification of Surgical Operations and Procedures, 4th Revision) for such procedures. The PCT will hold monthly meetings to review OPCS procedures to ensure compliance with low priority procedure policy. If such procedures are performed, funding will only be provided if prior written approval has been sought via the Exceptional Funding Panel, using the form provided. This form, when returned, should be filed in the patient notes for future audit purposes.
Threshold Procedures.
The PCT will undertake joint audit on threshold procedures on a regular basis (interval to be confirmed). Forms will be provided for each threshold procedure to permit future audit. These are included in the Low Priority Procedure Implementation Pack. The provider trust is expected to file the PCT policy checklist in the patient notes to facilitate subsequent ease of audit.