The purpose of our Service Restriction Policies is to ensure that Mid and South Essex Integrated Care System (ICS) fund treatment only for safe, evidence based, clinically effective interventions and services delivered to the right patients.
Our service restriction policies cover a number of interventions and services that Mid and South Essex ICS do not routinely fund. Patients should only be referred for the interventions and services listed in this policy if they meet the eligibility criteria set out in the service restrictions policy.
Interventions and services not currently commissioned through established care pathways or identified for funding through the commissioning process are not routinely funded.
The onus is on the clinician to ensure that appropriate authorisation from Mid and South Essex ICS is accessed. Authorisation will be achieved either by prior approval or, where there are significant numbers of procedures, by retrospective audit (as agreed per provider) to assure compliance with criteria. The clinician must provide sufficient information to evidence how the patient meets the criteria.
Mid and South Essex ICS will not pay for interventions or services in following circumstances:
- if a provider undertakes one of the interventions contained within these policies that requires prior approval and has not gained approval;
- if a provider undertakes one of the interventions contained within these policies that requires retrospective audit and is found not to meet the criteria when the audit is undertaken;
- if a provider undertakes an intervention that is not normally funded without gaining funding approval via an individual funding request,
Mid and South Essex ICS does not fund services covered by the NHS England Specialised Commissioning Group.
Types of service restriction policies:
Group Prior Approvals
Those procedures which are commissioned by M&SE ICS on a routine basis but only for patients who meet the defined criteria set out within this policy but for which individual prior approval is not required. ICS notification of compliance or audit will be required according to contractual arrangements.
Individual Prior Approvals
Those procedures which are commissioned by M&SE ICS but only for patients who meet the defined criteria set out within this policy and which require individual approval on a patient by patient basis. For these procedures, the criteria listed form guidance to both the referring and treating clinicians and if a patient is deemed to meet these criteria prior approval should be sought from the funding team at the ICS.
Not Normally Funded
Those procedures which have been assessed as treatments of low clinical effectiveness by Mid and South Essex ICS and which will not be funded unless there are exceptional clinical circumstances. Applications for funding for these procedures can be made to the Individual Funding Request Team but should only be made where the patient demonstrates true clinical exceptionality (see below for definition of exceptionality).
Individual Funding Requests
Mid and South Essex ICS always allows clinicians the opportunity to make specific funding requests via its individual funding request process.
Policy development is an on-going process in response to evidence published. If an intervention is considered appropriate for routine funding, there is an annual process to agree these within the contracts of providers.
The words “exceptional”, “exceptionality” and “exceptional clinical circumstances” bear their natural meanings as defined in the Oxford English Dictionary. However, the Integrated Care Board recognises that the meaning of these words has given rise to considerable difficulty in the past and offers the following guidance to assist the IFR Team, Panel and clinicians as to how to approach the meaning of the words.
There is a difference between “individual” and “exceptional”. Every patient has features of their condition which are specific to that individual and are not likely to be repeated in other patients with the same clinical condition at the same stage of progression of the condition. Exceptionality is not the same as individuality.
There are 2 tests to apply to exceptionality:
Test 1: 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?
Test 2: Would the patient be likely to gain significantly more clinical benefit from the requested intervention than might be normally expected for the general population of patients with the condition at the same stage of the progression of the condition?
To contact the IFR team please email [email protected].