Greater Manchester Directors of Commissioning

Document Sample
Greater Manchester Directors of Commissioning Powered By Docstoc
					NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




       EFFECTIVE USE OF RESOURCES

                POLICY AND APPLICATION
                      DOCUMENT




Version 2.2

Date of issue: 2nd December 2009
Date of Review: to be confirmed
Status: Final Draft for PEC
Author: Gideon Smith on behalf of EUR Policy Group




Date of issue: 2nd December 2009   Version 2.2
                                                                           -1-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




Document Control Page
Document Location

S:\Public Health\EUR\Effective Use of Resources Policyv2.2




 Document              Author                Comments                   Date
   Version
2.0              Gideon Smith      Draft for EUR Policy Group   28t h Sept 2009
2.1              Gideon Smith      Draft for PEC                20t h November 2009
2.2              Gideon Smith      Final Draft for PEC          2nd December 2009




Date of issue: 2nd December 2009      Version 2.2
                                                                               -2-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




Effective Use of Resources Policy

1.       BACKGROUND

1.1      The government's priorities for modernising the NHS are underpinned by
         achieving careful management of overall NHS resources. It also wants
         people wherever they live to have access to high quality services and care.

1.2      Consequently, Tameside and Glossop PCT needs to continue to improve the
         cost effectiveness of services it both provides to, and commissions for its
         population, thereby securing the greatest health gain from the resources
         available.    Decisions need to be based on evidence about clinical
         effectiveness. This policy document sets out the approach to making this
         happen.


2.       PRODUCTION OF THE POLICY

2.1      In drafting this policy, account has been taken of:

             the introduction of National Service Frameworks;
             guidance from the National Institute for Health and Clinical Excellence
              (NICE);
             the production of guidance on the work of the Clinical Governance
              Support Team and independent advice and expertise from the Care
              Quality Commission

2.2      The policy is to be set in context of the PCTs:

medicines management strategy;
clinical audit programme; and
financial position.

2.3      As partnership working continues to develop throughout Tameside and
         Glossop and across Greater Manchester, the PCT is conscious of the
         potential impact of its decisions on partner organisations and will scrutinise
         the effect of any policy decision for its impact on other agencies.

2.4      Where appropriate, it will seek to harmonise policies with Greater Manchester
         PCTs. Should potential problems be identified, these will be raised through
         the PCTs Medical Director or Director of Public Health, and brought to the
         Effective Use of Resources Policy Group or Medicines Management
         Committee as appropriate, for decision/ratification.

2.5      In drafting this policy, notice has been taken of the areas within the NHS
         modernisation agenda referring to patient information, choice and autonomy
         in making decisions about patient care. This policy adopts the principle that a
         clinician‟s decision to challenge this policy will not in any way prejudice the
         patient‟s NHS care pathway or timescale nor result in the exclusion of the
         patient from available NHS treatment.




Date of issue: 2nd December 2009      Version 2.2
                                                                                -3-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



3        ENSURING AVAILABLE RESOURCES ARE USED EFFECTIVELY

3.1      If the PCT is to improve the clinical effectiveness of the services it both
         provides directly and commissions for its population, it will be necessary to
         ensure there is a systematic process for assessing current and new
         treatments and for making best use of existing or new resources.

3.2      The PCTs Effective Use of Resources Policy Group of the Professional
         Executive Committee has devolved responsibility for ensuring that services
         that improve physical and mental wellbeing are provided and commissioned
         in accordance with best practice and effectiveness guidance.

3.3      Similarly, the Medicines Management Committee has devolved responsibility
         for securing access to appropriate pharmaceutical products either through
         primary care practitioners or making recommendations on the range of
         products and services to be provided through hospital-based Service Level
         Agreements.

3.4      These committees will want to receive and make recommendations for action
         upon information and intelligence collated from a number of sources, e.g.

         Clinical audit - a key element of strategy to ensure the effective use of
         resources. The PCT will co-ordinate local health communities/audit
         programmes. Audit outcomes will need to inform service delivery and the
         public.

         Clinical trials - some patients will receive new drugs/treatments as part of
         clinical trials. The PCT cannot guarantee the continuation of a new drug or
         treatment at the end of the trial. It is the responsibility of the Ethics
         Committee, and the principal investigator prior to the commencement of a
         research trial to ensure that adequate information is available to patients as to
         what will happen when the trial ends.

         NICE guidance - is issued on medicines or other medicines management
         related matters. The PCTs Medicines Management Committee will review
         and develop plans for local implementation. Where there are resource issues
         associated with NICE guidance, over and above the Operational Plan
         settlement, the PCT will undertake to have urgent discussions to resolve any
         difficulties. The PCT will facilitate collaboration between all parts of the
         service to assist with this. Providers will be required to meet NICE guidance
         within the Operational Plan financial settlement, to include in-year pressures
         should they arise.

         NSFs - all providers will be expected to adopt the principles of National
         Service Frameworks and achieve the milestones set out in them. Where
         there are resource issues associated with NSF guidance, over and above the
         Operational Plan settlement, the PCT undertakes to have urgent discussions
         to resolve any difficulties. Providers will be required to meet NSF standards
         and requirements within the Operational Plan financial settlement, to include
         in-year pressures should they arise.

         Greater Manchester Effective Use of Resources Group




Date of issue: 2nd December 2009     Version 2.2
                                                                                  -4-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



         Greater Manchester Medicines Management Group
         North West Specialist Commissioning Team
         Greater Manchester and Cheshire Cancer Network
         Tameside and Glossop Drugs and Therapeutics Committee -
         - policy statements developed by these collaborative groups will be reviewed
         by the Policy Group for inclusion in Annex A of this policy.

3.4      The Director of Public Health & Health Strategy will, on behalf of the
         Effective Use of Resources Policy Group, maintain and make widely
         available:

             a list of services where there is no clinical proven benefit and for which no
              resources are to be allocated either through a SLA or for an individual
              treatment/procedure;
             eligibility criteria for services accessed either through SLAs or on an
              individual patient basis


4        ESTABLISHING WHETHER SERVICES/TREATMENTS SHOULD BE
         COMMISSIONED BY THE PCT

4.1      The PCT will hold a list of services that will not be commissioned on the basis
         of there being no clinical proven benefit. The present list is set out at Annex
         A to this policy.

4.2      The Effective Use of Resources Policy Group, comprising majority clinical
         members, will consider new treatments and therapies, advising on whether
         they should be commissioned by the PCT and if so, whether the service
         should be commissioned under the terms of a Service Level Agreement or on
         an individual patient basis. Terms of Reference for the Policy Group are
         included at Appendix 2.

4.3      The decision will be based on the available evidence, both locally and
         nationally taking account of the principles set out in Section 3 and Annex D
         (Ethical Framework)..

4.4      The Policy Group which must always have majority clinical representation,
         membership is:




Date of issue: 2nd December 2009      Version 2.2
                                                                                   -5-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




             Director of Public Health and Health Strategy
             PCT Medical Director
             Medical Director, Tameside Hospital FT
             Chief Pharmacist, Tameside Hospital FT
             Pharmaceutical Advisor
             Director of Contracting and Performance
             EUR Administrator
             Director of Nursing & Provider Services
             Head of Continuing Care and Nursing
             Professional Executive Committee Representative
             Cons ultants in Public Health
             Mental Health Lead Commissioner
             PBC Repres entatives
             Senior Commissioning Manager – Mental Health and Learning Disabilities
             NICE Manager
             PALS Representative
             Patient and P ublic Involvement Representative
             Finance Repres entative
             Chair of Greater Manchester EUR Group (Standing Invitation)

The Group will take advice from other staff who shall be in attendance, including:
       Medicines management

4.5      Those treatments/therapies that are not to be commissioned will be added to
         the list and this shall then be circulated to clinicians throughout the area.


5        SECURING P ROVISION THROUGH S ERVICE LEV EL AGREEMENTS

5.1      The PCT‟s Commissioning and Market Management Executive, the EUR
         Policy Group and Medicines Management Committee are responsible for
         ensuring appropriate commissioning arrangements are in place, covering the
         application of resources either through service level agreements or one-off
         arrangements for treatment. They must ensure that there is clarity with
         providers, about financial responsibility for all aspects of SLAs, including
         responsibility for prescribing.

5.2      Wherever possible, services should be secured through a service level
         agreement, specifying the range and quality/outcome of services to be
         provided, as well as the volumes and values attached to the arrangement.

5.3      Fundamental to the commissioning process, should be a relationship between
         commissioners and providers which has the following characteristics:

             Providers deliver up-to-date clinical practice in an effective and efficient
              way
             Providers monitor the outcomes of the work they do to ensure that jointly
              agreed standards are met
             The results of audit should increasingly be shared within providers,
              between primary care practitioners and with commissioners.
             Providers and their clinicians should provide appropriate information to
              patients about the effectiveness of treatments offered so that their choices
              are properly informed.




Date of issue: 2nd December 2009       Version 2.2
                                                                                      -6-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




              An evaluative culture should develop within provider organisations,
               supported by appropriate structures, which both encourage this approach
               and ensure the review of the processes by which changes in clinical
               practice are introduced.
              The PCT will commission services in line the Local Delivery Plan
              In-year service pressures should be dealt with by the provider and
               managed in-year.
              Pressures/developments in a particular service are managed within the
               resources already committed to that service in global terms.
              Additional resources should only be made available through service
               agreements if it is decided that the relative priority of a service area is
               increased.
              Additional investment will usually only be made in an area which has
               undergone service redesign and/or critically examined current service
               provision.
              No additional resources will be made available unless circumstances are
               exceptional.


6        SECURING SERVICE               PROVISION      FOR     INDIVIDUAL      PATIENT
         TREATMENTS

6.1      Requests for individual patient treatments will be considered in line with
         the PCT operational policy set out at Appendix 1 to this Effective Use of
         Resources Policy. Where appropriate requests will be reviewed by the
         Individual Patient Request Panel (IPR Panel). The Term of Reference for the
         Panel are included in Appendix 2. Membership of the Panel is:

             Medical Director
             Associate Director of Contract Management, Procurement and Performance
             EUR Administrator
             Head of Continuing Care and Nursing
             Consultants in Public Health
             Mental Health Lead Commissioner
             PBC Representatives

             Senior Commissioning Manager – Mental Health and Learning Disabilities
             Finance Representative


6.2      The PCT has a wide range of Service Level Agreements with approximately
         twenty NHS Trusts and non-NHS organisations for the delivery of services.
         These should meet the vast majority of health requirements. The need for a
         separate, patient-specific agreement with these Trusts should be the
         exception to the rule. The need to refer outside of these should also be the
         exception to the rule.

6.3      Referral for individual patient treatments or procedures, which are agreed by
         the PCT to be of proven clinical value and not available within local Service
         Level Agreements, should not be questioned, save potential deferment in the
         event of in-year financial pressure. The decision to defer treatments will be
         taken by the EUR Policy Group or Medicines Management Committee based




Date of issue: 2nd December 2009       Version 2.2
                                                                                  -7-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




         on advice from the Medical Director and Directors of Finance and Public
         Health & Health Strategy . Under such circumstances, a clear protocol will be
         agreed to manage emergency and urgent treatments, and to ensure the PCT
         remains within waiting standards.

6.4      Should the service or treatment be available from a provider with whom there
         is an existing SLA, albeit as an exclusion to that SLA baseline value, the cost
         of individual patient treatments should be taken in to account when looking at
         the year-end SLA settlement.

6.5      Where the referral is to a provider with whom there is no SLA, local service
         providers should be asked to review whether they can make these services
         available.    Practitioners should take into account clinical and cost
         effectiveness and public health priorities before deciding to refer to service
         providers they do not normally use.

6.6      Individual patients should not be referred for treatments with no established
         proven clinical effectiveness. Such referrals will be returned to the referring
         clinician and/or GP with a letter of explanation copied also to the patient.

6.7      New treatments should not be introduced unless fully evaluated and approved
         by the PCTs EUR Policy Group or Medicines Management Committee as
         appropriate.

6.8      Individual referrals should not be made to service providers that are not
         normally used solely to avoid long waiting lists. Rather, concerns should be
         raised in the first instance with the PCT or provider concerned.

6.9      An approach should be adopted which provides no incentive for patients to
         move into an area and/or change their registered GP specifically to obtain a
         treatment that is not available in their original area of residence.

6.10     Any individual referrals directly to non-NHS organisations with whom there is
         no SLA will require authorisation from the PCT. (Appendix 1 – operational
         policy)

6.11     In general, a patient's request for a 'second opinion', should be met by referral
         to a different provider within existing SLAs


7        SERVICES WITH NO ESTABLISHED PROVEN CLINICAL
         EFFECTIVENESS

7.1      There are a number of treatments, procedures or therapies, which the PCT
         would not normally consider to support either through a SLA or individual
         patient treatment arrangement.

7.2      The PCT may place limitations on the level of service commission based on
         identified criteria because of low priority and limited effectiveness. These are
         listed in Annex A, along with the specific policy guidance that applies to each
         of them, agreed by the PCTs EUR Policy Group.




Date of issue: 2nd December 2009      Version 2.2
                                                                                  -8-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




7.3      For the purposes of this Policy a child is defined as under 19 years at the time
         of referral.


8        EXCEPTIONAL CIRCUMSTANCES

8.1      Where clinicians consider exceptional circumstances might justify an
         individual case being made an exception from this policy, they should make
         their case to the       PCT‟s Medical Director, outlining the exceptional
         circumstances.      They may be asked about the qualifications and
         effectiveness of the procedure and provider.

8.2      In deciding if a circumstance is “exceptional” the PCT will take account of
         previous decisions made under similar circumstances.

8.3      Requests will not be considered retrospectively for treatments, procedures or
         therapies and guidance relating to the use of local NHS capacity before
         contemplating resource to non-NHS service provision should be adhered to.
         If the referral is to a private facility, any financial or professional interest
         should be stated. NHS patients should not be referred to a facility with which
         the referring body may have a financial interest. Third party charges will not
         be refunded.

8.4      For a number of treatments, it is essential that the general practitioner has a
         detailed knowledge of the patient, which can only be gained over a period of
         time to be able to take a view on the appropriateness of the patient for referral
         for specialist assessment. With some procedures, for clinical reasons, a time
         period has been identified for which the patient should be registered with the
         same GP practice prior to referral for specialist assessment and/or treatment.


9        APPEALS

9.1      In all decisions where the PCT decides to refuse funding the patient and
         referring doctor will be notified of the appeals process. This is attached at
         Appendix 1.


10       MONITORING AND REVIEW

10.1     The policy will require ongoing monitoring and review to ensure that
         resources continue to be used effectively. As part of this process, the policy
         and specific proposals listed in the Annex A will be regularly reviewed based
         on new evidence and, other services/treatments may need to be considered
         in more detail to establish a recommended course of action This policy will be
         formally reviewed annually to inform service planning.


11       Further Information

Further information on this policy can be obtained by contacting:




Date of issue: 2nd December 2009     Version 2.2
                                                                                  -9-
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




Tameside & Glossop Primary Care Trust
New Century House
Windmill Lane
Denton
M34 2GP

Telephone: 0161 304 5300
Email:




Date of issue: 2nd December 2009   Version 2.2
                                                                           - 10 -
                                   NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                                                 Annex A


                                    Specific Treatment, Procedures or

                                     Therapies to which the policy will

                                                                    apply.




Date of issue: 2nd December 2009       Version 2.2
                                                                                 - 11 -
                                    NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 Specialty                 Procedure                      Policy position
 Alternative therapies     Applied kinesiology            These therapies will not normally be funded, in line with GME UR Policy Review No 14.
 not    available    in    Autogenic training
 contract                  Ayurveda
                           Environmental medicine
                           Healing
                           Homeopathy
                           Meditation
                           Naturopathy
                           Reiki
                           Shiatsu
 Canc er surgery           Keyhole Surgery For            For parathyroid cancers - keyhole surgery has no plac e currently in our Net work and cancer
                           Parathyroid Tumours            specialists would not recommend it to be commissioned. [GMEUR24]

 Complementary and         Acupuncture                    On existing available evidence the P CT would not normally support referral outside of the NHS
 Alternative Medicine      Alexander technique            for these services.
 (CAM)                     Aromatherapy                   GMEUR 14: CA Ms which have evidence of effectiveness for specific conditions (see
                                                          supporting guidance) may continue to be provided within NHS clinical governance
                           Chiropractic
                                                          arrangements. All providers of CA M must belong to a statutorily regulated organisation. No
                           Osteopat hy                    development of CA Ms should occur until there is further evidenc e of efficacy, safety and cost
                           Herbal medicine                effectiveness, preferably after consideration by the National Institute for Health and Clinical
                           Hypnosis                       Excellenc e.
                           Massage
                           Nutritional therapy
                           Reflexology
 Dent al                   Endosseous (dental) implants   This treatment is available at the Dental Hos pital and Royal Oldham Hospital where referrals
                                                          will only be accepted if they meet the criteria presently under review as set out in the attached
                                                          protocol – Annex C
 Dent al                   Multi-bridge dental work       Prior approval required.




Date of issue: 2nd December 2009         Version 2.2
                                                                                      - 12 -
                                    NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 Dermatology               Excision of benign skin lesions   This policy is not intended to apply to cases where the diagnosis of a benign condition is
                                                             uncertain, where the lesion causes significant pain or when the nature of the condition requires
                                                             immediat e treatment. The immediate treatment category can include benign lesions that are
                                                             significantly traumatised and/or have become infected.

                                                             The following procedures are generally performed for aesthetic reasons and not routinely
                                                             funded by the PCT.

                                                             If secondary referrals are made for these conditions for reasons stated above, they should be
                                                             made to Dermatologists [and not general surgeons] who have the best expertise to assess
                                                             suitability of minor surgery.

                                                             Definition
                                                             Benign skin lesions are thos e lesions that are not malignant, and include a range of cutaneous
                                                             lesionsincluding:

                                                             Benign pigmented moles              Molluscum contagiosum
                                                             Comedones                           Seborrhoeic kerat oses
                                                             Basal Cell Papillomata              Corn/callous
                                                             Skin tags                            Lipoma
                                                             Spider naevus (telangiectasia)      Male pattern baldness
                                                             Warts                               Milia
                                                             Sebaceous Cyst (Epidermoid cyst of the skin)

                                                             There are no restrictions on treatment of genital warts.
                                                             [GMEUR 19]




 ENT                       Bone Anchored Hearing Aid         Require prior approval




Date of issue: 2nd December 2009         Version 2.2
                                                                                         - 13 -
                                   NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 ENT                       Cochlear implants              Agreed contracts will give absolute priority to meningitis affected children, and include
                                                          unilateral and bilateral implants in line with NICE guidance TA116, Jan 2009. Sequential
                                                          implants will be considered on an exceptional case basis.

 ENT                       Surgical treatment for sleep   Funding will be case by case basis. The P CT will not normally fund t reatment when snoring is
                           apnoea or snoring              the sole problem. Only snorers with at least one of the following symptoms present should be
                                                          referred for assessment for sleep apnoea:
                                                          1. daytime sleepiness, not just tiredness (Epwort h Sleepiness Score >9);
                                                          2. witnessed regular or frequent episodes, as opposed to occasional, of stopping breathing
                                                          during sleep;
                                                          3. waking from sleep with choking / obstructed episodes;
                                                          4. regular waking feeling unrefreshed;
                                                          5. large neck circumference (17 inches or over) or significant retrognathism;
                                                          6. small oedematous phary nx on visual inspection.
 ENT                       Tonsillectomy                     Referrals for tonsillectomy are only accepted where patients meet the S IGN guideline 34,
                                                          Jan 99, criteria for referral:
                                                            ·   Sore throats are due to tonsillitis
                                                            ·    Five or more epis odes of sore throat per year
                                                            ·    Symptoms for at least a year
                                                            ·    Episodes of sore throat are disabling and prevent normal functioning

                                                            Following specialist referral, a six month period of observation is recommended to establish
                                                          the pattern of symptoms and allow the patient to consider the implications of the operation.



                                                            In addition the PCT may consider:
                                                            · Quinsy (Peritonsillar absess)
                                                            ·    Obstructive sleep apnoea
                                                            ·    Suspected or proven malignancy




Date of issue: 2nd December 2009           Version 2.2
                                                                                     - 14 -
                                    NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 ENT                       Surgical Treatment of Otitis   Insertion of grommets:
                           Media with Effusion (OME )
                                                          1. Children with persistent bilateral otitis media wit h effusion doc umented over a period of 3
                                                          months with a hearing level in the better ear of 25 -30 dBHL or worse, averaged at 0.5, 1, 2
                                                          and 4 Khz should be considered for surgical intervention.

                                                          2. Exceptionally, the insertion of grommets should als o be considered with a hearing loss of
                                                          less than 25-30 dB HL where the impact of the hearing loss on the child‟s developmental,
                                                          social or educational status is judged to be significant. This information should be contained
                                                          within the referrer‟s letter.
                                                          Children aged 18mths – 3yrs may require special consideration.
 Epilepsy Services         David Lewis Centre             The David Lewis Centre is a non-NHS organisation, which offers support, treatment and
                                                          diagnostic services for people with epilepsy. The David Lewis Cent re does not have 24-hour
                                                          medical cover or resuscitation facilities, therefore, before funding is agreed a risk assessment
                                                          by the referring clinician and David Lewis Centre will be made available to the PCT. Guidance
                                                          states that PCTs, GPs and NHS Trusts should explore the scope to make maximum cost
                                                          effective uses of local NHS capacity before contemplating recourse to the private sector
                                                          provision.


                                                          The David Lewis Centre offers videotelemetry – to support management of complex epilepsy,
                                                          which is not currently available within the NHS in Manchester (although there are facilities in
                                                          Oxford and Liverpool). In future, any referrals to the David Lewis Cent re will require the written
                                                          support of the GP having consulted with an appropriat e NHS cons ultant colleague confirming
                                                          that:

                                                          1. Patients have long standing epilepsy and/or possible non-epileptic attacks
                                                          2. All NHS avenues (including tertiary services provided by Hope Hospital) have been
                                                          explored.
                                                          3. Patients have significant psychiatric disorder and/or psychosocial distress in addition to their
                                                          seizures
                                                          4. They are high users of health care services with frequent hospital admission




Date of issue: 2nd December 2009         Version 2.2
                                                                                      - 15 -
                                    NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                                               5. They are in need of longer-term periods of assessment to optimise medical treatment and to
                                                               determine longer –term needs for social support and supervision in the community

                                                               6. On going follow up following assessment at the David Lewis Centre will be undertaken
                                                               within the NHS
                                                               7. One course of videotelemetry per patient.

                                                               The P CT will continue t o review closely the outcomes of referrals made to the David Lewis
                                                               Cent re.

 Gastroenterology          Hepatitis treatments including      Funded in line with relevant NICE guidance, or considered on an exceptional case basis.
                           ribavirin, pergylated int erferon
                           and entacavir
                                                               Individualised hepatitis C treatments, erythropoietin and filigastrim funded in line with GMMMG
                                                               guidance letter Sept 09.
 Gastroenterology          High cost drugs including           Funded in line with relevant NICE guidance, or considered on an exc eptional case basis.
                           adalimumab, infliximab.
 Gender dysphoria          Gender reassignment                 Patient with gender dysphoria should be registered with a Tameside & Glossop GP P ractice
                                                               for three years in order that they may have the opportunity to fully assess the clinical needs of
                                                               the patient. Referral will only be made through a NHS general psychiatrist with the support of
                                                               the patients GP. This service will be commissioned collaboratively via Salford P CT. It will form
                                                               the total resource for purchasing tertiary gender reassignment services.


                                                               Patients will enter a quota system based on the state of their gender dysphoria and their
                                                               clinical needs as assessed loc ally This financial limit may provide a waiting list, which
                                                               breaches current government targets. This P CT explicitly recognises a nd accepts this
                                                               implication. Waiting lists will be reviewed annually by the PCT and resource decisions made
                                                               taking into account waiting lists.


 General medicine          Chronic    Fatigue/      Multiple   Referrals to Manchester P CT service are usually funded.
                           Sclerosis Service




Date of issue: 2nd December 2009          Version 2.2
                                                                                           - 16 -
                                      NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 General medicine          High cost drugs          & other    Funded in line with relevant NICE guidance, or considered on an exceptional case basis.
                           treatments where         probably
                           benefit is low
 General medicine          Insulin pumps                       Requests in line with NICE guidance require prior approval.

 General medicine          Home delivered drugs                Referrals to BUPA and Calea are usually funded.

 General surgery           Surgical     management        of   Service is commissioned through NWSCT contract with Salford Royal University Hospital FT.
                           obesity
 General surgery           Varicose veins                      Surgical treatment of varicose veins will not normally be offered unless accompanied by the
                                                               following complications:
                                                               1. Persistent ulceration secondary to venous stasis after unsuccessful 6 month trial of
                                                               conservative management (compression stockings, exercise and daily elevation 2-3 times a
                                                               day)
                                                               2. Recurrent phlebitis where there is significant pain and disability from this condition and after
                                                               unsuccessful 6 month trial of conservative management (compression stockings, exercise and
                                                               daily elevation 2-3 times a day)
                                                               3. Significant haemorrhage from a ruptured superficial varicosity, for instance serious enough
                                                               to consider transfusion/admission


 Haematology               Haemophilia treaments               Exceptional requests (eg when required for surgery) would normally be funded

 Laser surgery             Hair removal
                                                               These procedures are commissioned in line with Modernisation Agency guidance "Information
                                                               for Commissioners of Plastic Surgery Services: Referrals and Guidelines in Plastic Surgery"
 Mental Health             Access to mental health             The P CTs occupational health s ervices arrangements for directly employed staff and General
                           services for NHS Staff for          practitioners shall apply.
                           psychological treatments for
                           alcohol abuse & post-traumatic
                           stress disorder




Date of issue: 2nd December 2009            Version 2.2
                                                                                           - 17 -
                                    NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 Mental Health             Alcohol treatment (bey ond           Requests for treatments should normally be referred within contract to NHS/social care and
                           those services provided within       voluntary s ector providers in Tameside and Glossop and Manchester. Referral elsewhere
                           contract).                           should only be in exceptional c ases where a cost-effective t reatment is available and when all
                                                                local treatment options under contract have been explored.
 Mental Health             Combat stress (beyond those          Requests for treatment outside contract in Tameside & Glossop and Manchester should only
                           services   provided   within         be in exceptional cases and any referrals should require the support of a local psychiatrist
                           contract)

 Mental Health             Hypnotherapy     for     irritable   Considered on an individual case basis for funding in lin e with NICE guidanc e.
                           bowel syndrome
 Mental Health             Eating disorders                     Requests for outpatient assessment, CB T or counselling are usually funded and provided by
                                                                Affinity Health Care at Cheadle Royal Hospital.
 Mental Health             Psychosexual services                Requests for outpatient assessment are usually funded and provided by CMFT.

 Neurology                 Functional Electrical Stimulator     Requests from UHSMFT and SRUHFT are usually funded.
                           implants
 Neurology                 High cost drugs including            Funded in line with relevant NICE guida nce, HSC 2002/004 or considered on an exceptional
                           betaferon and natalizumab            case basis.
 Obstetrics &              Diagnostic     dilation      and     This procedure should only be undertaken in exceptional circumstances as evidence in
 gynaecology               curettage for women <40              Effective Healthcare Bulletin 9 identified the risks of anaesthesia, uterine perforation and
                                                                cervical laceration out weighing the minimum potential benefit. Policy further endorsed by
                                                                NICE guidance CG44 "Heavy Menstrual Bleeding" Jan 2007.


                                                                GMEUR37: Greater Manchester P CT’s will not normally commission dilatation and curettage
                                                                (D& C) as a therapeutic intervention for women with heavy menstrual bleeding (menorrhagia);
                                                                irregular periods; or endometrial hyperplasia (thick ened lining of the uterus), and this surgery
                                                                has a LOW PRIORITY. D&C alone should not be used as a diagnostic tool but may be
                                                                undertak en as an aid to diagnosis of the causes of abnormal uterine bleeding.




Date of issue: 2nd December 2009          Version 2.2
                                                                                            - 18 -
                                   NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 Obstetrics &              Hysterectomy                  Greater Manchester PCT‟s will commission hysterectomy for appropriate patients with a
 gynaecology                                             diagnosis of:
                                                         • cancer of the cervix / fallopian tubes / uterus and/or ovaries
                                                         • severe and debilitating endometriosis or adenomyosis that cannot be managed by non-
                                                         surgical interventions
                                                         • uterine prolapse, where non-surgical options are inappropriate or have failed to
                                                         manage the woman‟s symptoms
                                                         • complicated and persistent pelvic inflammatory disease that has not responded to
                                                         conventional treatment


                                                         With regarding to women diagnosed with menorrhagia (heavy menstrual bleeding) and/or
                                                         dysmenorrhoea (painful menstruation), with or wit hout fibroids, hysterectomy will not be
                                                         commissioned as a first-line treatment.

                                                         Hysterectomy will be commissioned for menorrhagia and/or dysmenorrhoea only when:
                                                         • other treatment options for heavy menstrual bleeding, dysmenorrhoea (and/or symptomatic
                                                         large or multiple fibroids) have failed or are contraindicat ed
                                                         AND
                                                         • there is a wish for amenorrhoea (absenc e of menstruation);
                                                         AND
                                                         • the woman no longer wishes to retain her ut erus and fertility;
                                                         AND
                                                         • the woman (who has been fully informed) requests hysterectomy.




Date of issue: 2nd December 2009          Version 2.2
                                                                                   - 19 -
                                     NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                                           In all instanc es, women offered hysterectomy should:
                                                           • have a full discussion of the implication of the surgery before a decision is made. The
                                                           discussion should include: fertility impact; bladder function; need for further treatment;
                                                           treatment complications; sexual feeling; the woman‟s expectations; alternative surgery; and
                                                           psychological impact.
                                                           • be informed about the increased risk of serious complications (such as
                                                           intraoperative haemorrhage or damage to other abdominal organs ) associated
                                                           with hysterectomy when ut erine fibroids are present
                                                           • be informed about the risk of possible loss of ovarian function and its
                                                           consequences, even if their ovaries are retained during hysterectomy.


 Obstetrics &              In-vitro fertilisation          This treatment will only be purchased from St Mary‟s Hospital, Central Manchester Healthcare
 gynaecology                                               NHS Trust within the terms of the current referral protocol, which exists – Annex B. General
                                                           practitioners will not prescribe drugs on the NHS for patients undergoing IVF via a privat e
                                                           provider.
 Oncology                  Bone marrow transplants         Require prior approval

 Oncology                  Expensive drug & ot her         Funded in line with relevant NICE guidance, or considered on an exceptional case basis.
                           treatments   for   advanced
                           cancer where probably benefit
                           is low
 Ophthalmology             Anti VEGFs for Age Related      Funded in line with NICE guidance TA115, Aug 08, as part of GMAN Trial or IVAN Trial.
                           Macular Degeneration
 Orthopaedics              Endoscopic Lumbar               This intervention should not be commissioned routinely but PCTs may consider
                           Decompression                   commissioning as part of a peer reviewed randomised controlled trial. [GMEUR12]

 Paediatrics               Donor breastmilk                Considered on exceptional case basis. Requires support from Donor Milk Bank, and preferably
                                                           a dietitian.




Date of issue: 2nd December 2009            Version 2.2
                                                                                      - 20 -
                                   NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 Physiotherapy             Bobath Therapy                    Historically the PCT and its predecessors have funded the Cent re costs for children to attend
                                                             the centre following the request of their Paediatrician, usually responding to a Physio or OT
                                                             request. The child‟s family has had to fund travel, accommodation in London for the treatment
                                                             period – usually for 2 weeks. The outcome of the assessment is a comprehensive assessment
                                                             and detailed individualised home programme. Copies of this are supplied to parents and all the
                                                             child‟s key health workers locally. The reports usually include the rec ommendation of a follow-
                                                             up two-week assessment 12 months later. [GME UR Policy 21]



 Physiotherapy             Requests for therapies not        Requests for therapy at CMFT usually funded.
                           available from THFT
 Plastic & cosmetic                                          These procedures are commissioned in line with Modernisation Agency guidance "Information
 surgery                                                     for Commissioners of Plastic Surgery Services: Referrals and Guidelines in Plastic Surgery"
                           Abdominoplasty (tummy tuck)
                           Adult bat ears                    19 years or over at time of referral
                           Breast    augmentation   and
                           reduction                         The PCT does not commission cosmetic breast augment ation, breast reduction surgery or
                                                             corrective treatment following breast surgery undertaken withi n the private sector.
                           Buttock lift
                           Canc er reconstruction surgery
                           Cosmetic abdominal lipectomy
                           Cosmetic blepharoplasty
                           Cosmetic liposuction
                           Cosmetic rhinoplasty (nose
                           restructuring)
                           Cosmetic surgery of the nipple
                           Hair removal
                           Hair transplant
                           Mastopexy       (reposition  of
                           nipple)




Date of issue: 2nd December 2009         Version 2.2
                                                                                         - 21 -
                                   NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                           Non acute repair of split ear
                           lobes
                           Other cosmetic procedures
                           Penile Prosthesis (for cosmetic
                           reasons)
                           Pigeon Chest (and other
                           Cardiothoracic surgery for
                           cosmetic reasons)
                           Surgery to the ageing face
                           (face lift)
                           Tattoo removal
 Respiratory               Aspergillosis treatments
 medicine                                                    Requests from UHSM Regional Unit for voriconazole or posaconazole are usually funded.
 Respiratory               Cough assist machines
 medicine                                                    Requests from UHSMFT are usually funded.
 Respiratory               Pulmonary Hypertension
 medicine                                                    Require prior approval in line with GME UR Policy no 6, Sept 04. Most cases are national
                                                             centres at Sheffield or Newcastle. Only patients who do not respond to sildenafil should be
                                                             considered for treatment with an endothelian receptor ant agonist (bosentan) or a prostacyclin
                                                             (epoprostenol treprostinil). As all these drugs have been shown to have some degree of
                                                             effectiveness but have not been directly compared, the choice of drug shoul d therefore be
                                                             based on whichever is least expensive.

 Rheumat ology             High cost drugs including         Funded in line with relevant NICE guidance, or considered on an exceptional case basis.
                           adalimumab,       etanercept,
                           rituximab
 Spinal services           The Spinal Foundation             The Spinal Foundation is a non-NHS organisation, which treats patients with certain spinal
                                                             conditions often using laser surgery. The P CT has ent ered in to a collaborative commissioning
                                                             arrangement for a randomised control trial at the Spinal Foundation. Re ferrals to this service
                                                             will be via cons ultant ort hopaedic surgeons at the TGH. Otherwise, referrals to the Spinal
                                                             Foundation would not be supported.




Date of issue: 2nd December 2009         Version 2.2
                                                                                        - 22 -
                                     NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




 Urological surgery        Reversal of sterilisation (male      Normally, patient consent for sterilisation within the NHS states that this procedure is not
                           & female)                            reversible. The PCT therefore does not normally commission reversal of sterilisation.


 Urological surgery        Para-urethral silicon injections     Funded in line with relevant NICE guidance, IPG 138, Nov 05.
                           for incontinence.
 Vascular surgery          Aortic,   fenestrated   or   iliac   Require prior approval.
                           stents
                                                                GMEUR 36: In view of the present uncert ainty on the long term durability of stents, patients
                                                                should have a life expectancy of less than a decade. In general this will mean that they will be
                                                                >65 years.

                                                                Patients should be deemed fit for open repair by the referring team


                                                                Although assessment of operative risk is largely empirical, to support consistency across units
                                                                referral criteria will include a standardised scoring system to confirm higher risk status. V
                                                                Possum has been chosen as the risk assessment most lik ely to ans wer this need. Its
                                                                sensitivity and specificity will be k ept under review.
                                                                Aneurysm diameter (Dmax) should be greater than 55mms
                                                                Neck length should be >15mms. Neck diameter should be < 32mms
                                                                At least one iliac system (external and common ileac artery) must be patent with a minimum
                                                                diameter (Dmin) equal to or greater than 7mms.




Date of issue: 2nd December 2009          Version 2.2
                                                                                            - 23 -
                                   NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                                         Patients <65years or a with a life expectancy of more than a decade and those with low
                                                         mortality risk scores may be considered for endovascular repair, only after prior agreement of
                                                         the relevant PCT. It is anticipated that the majorit y of such requests will arise from the
                                                         following circumstances:

                                                         a) Hostile abdomen defined as: multiple (> 2) previous laparotomies, enterostostomy, previous
                                                         extensive radiotherapy, other causes of extensive internal scarring or adhesions, morbid
                                                         obesity ie BMI of 40k g/m2.
                                                         b) Co-existent malignancy awaiting primary surgical intervention (with expected survival >5
                                                         years)
                                                         c) Co morbidity not described elsewhere.




Date of issue: 2nd December 2009       Version 2.2
                                                                                    - 24 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                   Annex B

  Guidelines for assisted conception

     at St Mary’s Hospital, Manchester




Date of issue: 2nd December 2009   Version 2.2
                                                                           - 13 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




  Greater Manchester and Lancashire and
           South Cumbria PCTs

              Assisted Conception Taskforce

   An Integrated Approach to NHS Funded
           Treatment of Subfertility

1 Eligibility Criteria *

                                    June 2006




    *    Inclusion of Lancashire & South Cumbria PCTs subject to outcome of public consultation
                                            exercise.




Date of issue: 2nd December 2009       Version 2.2
                                                                                      - 14 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



Contents                                                                        Page
INTRODUCTION                                                                                3

COVERA GE OF CRITERIA                                                                       3

CLINICAL ELIGIBILITY CRITE RIA                                                              3

NON CLINICAL ELIGIB ILITY CRITERIA                                                          6

ELIGIBILITY CRITERIA APPLICABLE TO SAME SEX COUPLES                                     7

PROVIDER UNITS                                                                              7

APPEALS                                                                                     7
Appendix 1 – Policy Timeframe                                                           8

Appendix 2 – NICE algorithm (not attached in this version as file too large)     9 + 10




Date of issue: 2nd December 2009       Version 2.2
                                                                               - 15 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




1.     INTRODUCTION

       1.1      PCTs are using different clinical and social eligibility criteria for access
                to subfertility services. The PCTs in Greater Manchester have decided
                to adopt a unified commissioning approach both in the interests of the
                public (not least to reduce the incidence of the so-called ‟postcode„
                lottery regarding access) and service providers. It is recognised that
                achieving this unified approach will take time - a provisional timetable is
                set out in Appendix 1.

       1.2      PCTs have been asked to set aside sufficient resources to achieve a maximum
                18-month wait for IVF/ICS I (from the time of decision to treat by the tertiary
                provider) by March 2007. Progress towards this target will be reviewed in April
                2006 and any additional resources required to achieve the target will be identified
                in discussion with potential providers. Once the 18-month maximum wait is
                achieved, a review of service provision will be undertaken to determine priority
                areas for the next stage of implementation.

       1.3      Where, exceptionally, a couple have a stable relationship but are not co-habiting
                at the time of treatment the host PCT for commissioning purposes should be
                assumed to be that of the female partner.


2.     APPLICATION OF CRITERIA

       2.1      These criteria apply to clinical interventions, the primary intention of which is the
                treatment of subfertility. The details of the treatments can be found in the National
                                                                              1
                Institute for Clinical Excellence (NICE) Clinical Guideline 11 .

       2.2      The eligibility criteria do not apply to clinical investigations for subfertility or to
                relatively straightforward treatments, because the provision of such treatments
                does not require high levels of specialist skills and can be very effective.


3      CLINICAL ELIGIBILITY CRITERIA

       3.1      NICE Guidance

                Greater Manchester PCTs will fund, collaboratively, the specialised investigation
                and treatment for subfertility that are in accordance with the guidance contained
                within clinical guideline number 11, produced by the National Institute for Clinical
                Excellence. It is expected that management will be in line with the clinical practice
                algorithm contained in this guidance (see Appendix 2). It is recognised t hat there
                may be instances in which the circumstances of an individual patient may suggest
                to the clinician that appropriate clinical management requires departure from this
                advice. Where such a departure may lead to an additional charge to the
                commissioner the clinician is advised to discuss the situation with their trust to
                seek approval from the commissioning body for funding before proceeding.


       3.2      Definition of Infertility and Access to Treatment

                NICE defines infertility as ‘failure to conceive after regular unprotected sexual
                intercourse for 2 years in the absence of known reproductive pathology’ (excluding
                couples using contraception and those outside the reproductive age range) The




Date of issue: 2nd December 2009          Version 2.2
                                                                                             - 16 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



                guidance advises that ‘couples who have not conceived after 1 year of regular
                unprotected sexual intercourse should be offered further clinical investigation
                including semen analysis and/or assessment of ovulation’.

       3.3      Where there is a known cause of infertility or there are other risks, such as the
                health of one of the partners, or where the female partner is aged 35 or over,
                earlier investigations should be offered.

       3.4      Treatment for couples with a known family history of an inheritable disorder may
                be undertaken after detailed consultation with an appropriate specialist. If
                treatment requires additional funding, approval should be sought from the relevant
                PCT.

       3.5      Smoking

                Smokers (both partners) would be expected to stop smoking before being
                accepted for treatment (i.e. added to the waiting list) and continue not to smoke
                whilst waiting for and during treatment.

       3.6      Weight

                Women would be expected to achieve a body mass index (BMI) of 19-29 before
                being accepted for treatment and to maintain that whilst waiting for and during
                treatment. It is recognised, however, that whilst waiting lists are in excess of 12
                months it would not be unreasonable for patients to demonstrate progress in
                achieving an appropriate BMI in order to be added to the list. However, treatment
                will not be commenced until their BMI is within this range.

       3.7      Drugs and Alcohol

                Couples will be asked to give an assurance, before being added to the list, that
                their alcohol intake is within Department of Health guidelines and they are not
                using recreational drugs. Any evidence to the contrary will result in removal from
                the list.

       3.8      Support to Patients in Primary Care

                The attention of GPs and secondary care clinicians in particular is drawn to the
                criteria in 3.5 - 3.7 above. Patients should be offered appropriate counselling and
                support, e.g. access to smoking cessation therapy, and advised at an early stage
                that they will not be accepted for treatment unless they satisfy these criteria.


       3.9      Access to High Level Treatments

                In view of present waiting times, treatment, including intra-uterine insemination
                (IUI) but excluding in-vitro fertilisation (IVF)/ intra-cytoplasmic sperm injection
                (ICSI) for unexplained subfertility, will be funded for couples who have been
                attempting to conceive for at least 12 months.

       3.10     Couples requiring donor insemination will be added to the tertiary centre waiting
                list as soon this requirement is identified.

       3.11     IVF/ICSI will be offered to eligible couples who have a 2 year history of subfertility
                except couples where the female partner is aged over 35 who will be considered
                for treatment with a minimum 12 month history of subfertility at the time of the
                             th
                woman‟s 35 birthday.




Date of issue: 2nd December 2009          Version 2.2
                                                                                            - 17 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




       3.12     IVF for couples who need a surrogate host will be considered when clinically
                indicated. The NHS will not, however, be involved in the surrogate procurement
                process.

       3.13     IUI/DI/IVF/ICSI – Age Range

                IUI/DI/IVF/ICSI will be offered to couples in which the woman is aged 23-39 at the
                time of treatment. This criterion applies irrespective of the number of cycles per
                couple e.g. where a PCT commissions 2 IVF cycles per couple both cycles must
                                                              th
                be commenced before the woman‟s 40 birthday. There is no specific age
                criterion for a male partner (the age of the male partner should be considered with
                reference to the overall welfare of the child).

                NB: NICE did not specify an age range for IUI/DI so for the purpose of this policy it
                is assumed to be the same as for IVF

       3.14     IUI/DI – Number of Commissioned Cycles

                Couples with mild male factor fertility problems, unexplained infertility or minimal to
                mild endometriosis can be offered up to 6 cycles of stimulated intra-uterine
                insemination. Couples for whom donor insemination is appropriate will be offered
                up to 6 cycles of unstimulated intra-uterine insemination.

       3.15     Couples who fail to achieve a pregnancy using IUI/DI will be considered for
                IVF/ICSI. (Couples for whom IUI/DI may be inappropriate may also be considered
                for IVF/ICSI)



       3.16     IVF – Definition and Number of Commissioned Cycles

                A cycle is the process whereby one course of IVF commences with ovarian
                stimulation and is deemed to be complete when all suitable embryos, fresh and
                frozen, have been replaced. Issues concerning abandoned cycles (their definition
                and costing) are still being considered by the taskforce. All Greater Manchester
                PCTs are commissioning at least one cycle of IVF per couple (but see 3.17
                below). Those commissioning more than one cycle will continue to do so.

       3.17     Maximum Number of Cycles

                The NHS will only fund up to a maximum of 6 IUI and 3 IVF/ICSI treatment cycles
                for each couple, irrespective of where those cycles have previously been
                provided, as the effectiveness after 3 cycles is less certain. If, for example, a
                couple have had 3 IVF cycles funded privately without success they would not be
                entitled to an NHS funded cycle even if their PCT funded up to 3 cycles.

       3.18     Individuals in a New Relationship

                Individuals will be entitled to a maximum of 3 IVF/ICSI cycles irrespective of the
                number of their relationships. Where a PCT funds only 1 cycle an individual may
                be eligible for treatment, i.e. IVF/ICSI, within a new relationship, even if they have
                had IVF/ICSI previously, providing the nature of previous subfertility is not clearly
                linked to that individual and there are no concerns with regard to the welfare of the
                child.

       3.19     Sterilisation




Date of issue: 2nd December 2009          Version 2.2
                                                                                             - 18 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                The surgical reversal of sterilisation and subfertility treatment for couples where
                one or other is sterilised would only be considered in very exceptional
                circumstances, e.g. the death of a child.

       3.20     Number of Embryos to be Transferred

                Couples will be counselled about the risks associated with multiple pregnancy and
                advised to consider the replacement of a single embryo per procedure within a
                cycle. In any event a maximum of two embryos will be transferred per procedure.


4.     NON - CLINICAL ELIGIBILITY CRITERIA

       4.1      Childlessness

                IUI, DI, IVF and ICSI will be funded for couples provided that one of the partners
                does not have any live children of any age (i.e. one partner does not have any live
                children; the other partner may have). This minimum standard is to be adopted for
                new referrals from April 2007. PCTs that have a more generous eligibility criterion
                (e.g. that either partner may have children from a previous relationship) may
                continue to use this criterion.

       4.2      A child adopted by the couple or adopted in a previous relationship is considered
                to have the same status as a biological child.

       4.3      Once accepted for treatment, should a child be adopted or a pregnancy leading to
                a live birth occur, the couple will no longer be eligible for treatment.


5.     ELIGIBILITY CRITERIA APPLICABLE TO SAME SEX COUPLES

       5.1      The guiding principles adopted by the taskforce have been those of equity of
                access and the best use of NHS resources, targeted towards childless couples.
                The taskforce awaits further guidance from the government regarding access to
                subfertility services by same-sex couples following the outcome of the national
                public consultation regarding the Human Fertilisation and Embryology Act and in
                the context of the Human Rights Act and the Civil Partnerships Ac t. Individuals in
                such relationships should have access to professional expertise in reproductive
                medicine to obtain advice on the options available to them within and outside the
                NHS.

6.     PROVIDER UNITS

       6.1      The Human Fertilisation and Embryology Authority (HFEA) regulates, by means of
                a licensing system, any treatment that involves the creation, keeping and using of
                human embryos outside the body. Within the code of practice of the HFEA are
                requirements for clinics to have regard to both the welfare of individuals seeking
                treatment and that of any child who may be born or affected as a result of
                treatments. All our provider units must meet this requirement regardless of any
                eligibility criteria established by any commissioning body.

       6.2      In addition, PCTs require provider units to be able to comply with the National
                Institute for Health and Clinical Excellence clinical guidance on the assessment
                and treatment of people with fertility problems with regard to the principles of care,
                presence of multi-disciplinary teams and treatment protocols of units.




Date of issue: 2nd December 2009          Version 2.2
                                                                                            - 19 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



7.     APPEALS

       7.1         The taskforce recognises that couples may wish to appeal against a decision to
                   refuse subfertility treatment. To deal with such appeals consistently and equitably,
                   it is proposed to establish an appeals committee on behalf of all Greater
                   Manchester PCTs. The committee will contain the necessary skills, knowledge
                   and experience required to judge each appeal. This multi-disciplinary committee
                   would be mainly drawn from amongst the PCTs and will be f acilitated by Ashton,
                   Leigh & Wigan PCT as the lead commissioner.


PFC June 2006




                                                                                    Appendix 1

 Greater Manchester (and Lancashire and South Cumbria
                        PCTs)
            Assisted Conception Taskforce
             Provisional Policy Implementation Timetable


                                   Policy                                      Timeframe

              Recurrent funding for one cycle of                            From April 2005
              IVF/ICSI to women aged 23-39



              Adoption of GM PCT joint commissioning                        From April 2006
              policy



              Adoption of revised childlessness criteria                      By April 2007




              Achievement of 18 month maximum wait                            By April 2007
              (subject to funding)




Once the 18-month maximum wait has been achieved it will be appropriate to review the
criteria and determine whether to:

              a.     provide recurrent funding for 2 cycles (where not already funded) or
              b.     revis e the interpret ation of childlessness to extend the eligible patient group
                     or




Date of issue: 2nd December 2009            Version 2.2
                                                                                              - 20 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



              c.   target a maximum wait of 12 months for couples with unexplained fertility

At that time it would als o be expected to review the rights of access to subfertility treatments
for same-s ex couples and individuals following the review of the HFEA and any other
guidance issued by the government.
         .




Date of issue: 2nd December 2009         Version 2.2
                                                                                        - 21 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                   ANNEX C



 Establishing the protocol for the
     funding of endosseous
         (dental) implants




Date of issue: 2nd December 2009    Version 2.2
                                                                           - 22 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                                                                 Annex C




Protocol for the funding of endosseous (dental) implants

INTRODUCTION

         The NHS receives a finite resource allocation to meet the health needs of its
          resident population. This resource has to be allocated with the knowledge
          that increased resources for one item of care can only be met by reductions
          in other areas. This protocol is open to further discussion about treatments
          as clinical circumstances change.

         Treatment to replace missing teeth by endosseous implants rather than
          dentures or bridges is becoming widely known to residents and increasingly,
          expectations of receiving this treatment are being raised. The PCT is not
          likely to be in a position to provide for every patient wishing to have implant
          treatment without severely compromising resources available for other
          equally desirable treatment.

         A decision has been taken therefore, to establish priorities for implant
          treatment and produce a protocol for General Dental Practitioners (GDPs) in
          Manchester and hospital units providing this treatment. Patients can then be
          advised on whether NHS treatment would be likely to be approved thus
          avoiding inappropriate referrals.

ESTABLISHING THE PROTOCOL

         As referrals for these procedures mainly come from General Dental
          Practitioners, they should be involved in the process of drawing up the
          protocol. Likewise, the consultants providing this type of treatment, both
          surgeons and restorative dentists will also need to be closely involved. The
          protocol was discussed and agreed by the Oral Health Advisory Group.

PRIORITIES

         The PCT will fund, subject to approval, implant treatment for residents in the
          following categories:

         As part of surgical reconstructive treatment to the mouth and surrounding
          tissues following having surgery where the bone loss is such that only
          implants can be used

         As part of oral and facial reconstructive therapy following severe facial
          trauma or ablative surgery for cancer

         Rehabilitation of patients with congenital defects for example, cleft palate or
          multiple congenitally missing teeth (oligodontia)

         Where there are severe eating or speaking disorders or severe psychological




Date of issue: 2nd December 2009     Version 2.2
                                                                                 - 23 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



          problems arising from the inability to wear a conventional dental prosthesis

         Where previously approved implant treatment has failed but subject to a
          report which indicates a good prognosis

         The PCT‟s will not approve implant treatment for patients where the primary
          reason for such treatment is patient preference or for aesthetic reasons
          unless the case also falls into one of the above categories.

PROCEDURE

         The SLA‟s with hospital units providing this form of treatment will include an
          identified resource for a defined annual number of implants for the PCT
          residents.

         Details of referred patients who meet the above criteria should be sent to the
          PCT together with a statement of need from the consultant to whom the
          patient was referred including, the reasons why conventional treatment
          (dentures and bridges) are not feasible or appropriate. Following this, the
          PCT will decide on whether treatment can be approved. The decision will be
          made initially by the PCTs Director of Dental Public Health.

         Variance from the contract numbers will be discussed at review meetings
          between the PCT and the relevant provider unit.

         The provider unit will be expected to inform patients and referrers if their
          clinical condition does not fall within the priority categories l isted above and
          therefore unlikely to receive PCT approval. The PCT will be responsible for
          informing patients and referrers if, following referral for approval, treatment
          with dental implants is not approved. General Dental Practitioners and
          consultants in oral and maxillo-facial surgery and restorative dentistry can
          discuss individual cases with the consultant in dental public health if
          necessary.




Date of issue: 2nd December 2009      Version 2.2
                                                                                  - 24 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                   ANNEX D



                        Ethical Framework




Date of issue: 2nd December 2009    Version 2.2
                                                                           - 25 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




Purpose of the Ethical Framework

The purpose of the ethical framework is to support and underpin the decision
making processes of the Effective Use of Resources Policy Group to support
consistent commissioning policy through:

Providing a coherent structure for discussion, ensuring all important aspects
of each issue are considered
Promoting fairness and consistency in decision making from meeting to
meeting and with regard to different clinical topics, reducing the potential for
inequity
Providing a means of expressing the reasons behind the decisions made.
Reducing risk of judicial review by implementation of robust decision-making
processes that are based on evidence of clinical and cost effectiveness and
an ethical framework
Supporting and integrating with the development of PCT Commissioning
Plans

Formulating policy recommendations regarding health care priorities involves
the exercise of judgment and discretion and there will be room for
disagreement both within and outwith the Policy Group. Although there is no
objective or infallible measure by which such decisions can be based, the
Ethical Framework enables decisions to be made within a consistent setting
which respects the needs of individuals and the community. The EUR Policy
Group recognises that their discretion may be affected by National Service
Frameworks, National Institute for Health and Clinical Excellence (NICE)
technology appraisal guidance and Secretary of State Directions
to the NHS.

The Ethical Framework is especially concerned with the following:

1. EVIDENCE OF CLINICAL AND COST EFFECTIVENESS

The EUR Policy Group will seek to obtain the best available evidence of
clinical and cost effectiveness using robust and reproducible methods.
Methods to assess clinical and cost effectiveness are well established. The
key success factors are the need to search effectively and systematically for
relevant evidence, and then to extract, analyse, and present this in a
consistent way to support the work of the Group. Choice of appropriate
clinically and patient-defined outcome needs to be given careful consideration,
and where possible quality of life measures and cost utility analysis should be
considered.

The Policy Group will promote treatments for which there is good evidence of
clinical effectiveness in improving the health status of patients and will not
normally recommend treatment that is shown to be ineffective. Issues such as




Date of issue: 2nd December 2009   Version 2.2
                                                                           - 26 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



safety and drug licensing will also be carefully considered. When assessing
evidence of clinical effectiveness the outcome measures that will be given
greatest importance are those considered important to patients‟ health status.
Patient satisfaction will not necessarily be taken as evidence of clinical
effectiveness. Trials of longer duration and clinically relevant outcomes data
may be considered more reliable than those of shorter duration with surrogate
outcomes. Reliable evidence will often be available from good quality,
rigorously appraised studies. Evidence may be available from
other sources and this will also be considered. Patients‟ evidence of
significant clinical benefit is relevant.

The Policy Group will compare the cost of a new treatment to the existing care
provided and will also compare the cost of the treatment to its overall benefit,
both to the individual and the community. They will consider technical cost-
benefit calculations (e.g. quality adjusted life years), but these will not by
themselves be decisive. The Policy Group may use the ethical framework to
guide context specific judgements about the relative priority that should be
given to each topic.

2. EQUITY

The Policy Group believes that people should have access to health care on
the basis of need. There may also be times when some categories of care are
given priority in order to address health inequalities in the co mmunity.
However, the Policy Group will not discriminate on grounds of personal
characteristics, such as age, gender, sexual orientation, gender identity, race,
religion, lifestyle, social position, family or financial status, intelligence,
disability, physical or cognitive functioning. However, in some circumstances,
these factors may be relevant to the clinical effectiveness of an
intervention and the capacity of an individual to benefit from the treatment.


3. HEALTH CARE NEED AND CAPACITY TO BENEFIT

Health care should be allocated justly and fairly according to need and
capacity to benefit, such that the health of the population is maximised within
the resources available. The Policy Group will consider the health needs of
people and populations according to their capacity to benefit from health care
interventions. So far as possible, it will respect the wishes of patients to
choose between different clinically and cost effective treatment options,
subject to the support of the clinical evidence.

This approach leads to three important principles:
In the absence of evidence of health need, treatment will not generally
be given solely because a patient requests it.
A treatment of little benefit will not be provided simply because it is the
only treatment available.




Date of issue: 2nd December 2009   Version 2.2
                                                                           - 27 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



Treatment which effectively treats “life time” or long term chronic
conditions will be considered equally to urgent and life prolonging
treatments.


4. COST OF TREATMENT AND OPPORTUNITY COSTS

Because the PCT is duty-bound not to exceed its budget, the cost of
treatment must be considered. The cost of treatment is significant because
investing in one area of health care inevitably diverts resources from other
uses. This is known as opportunity costs and is defined as benefit foregone,
or value of opportunities lost, that would accrue by investing the same
resources in the best alternative way. The concept derives from the notion of
scarcity of resources. A single episode of treatment may be very expensive, or
the cost of treating a whole community may be high.


5. NEEDS OF THE COMMUNITY

Public health is an important concern of the Policy Group and they will seek to
make decisions which promote the health of the entire community. Some of
these decisions are promoted by the Department of Health (such as the
guidance from NICE and National Service Frameworks). Others are produced
locally. The Policy Group also support effective policies to promote preventive
medicine which help stop people becoming ill in the first place.

Sometimes the needs of the community may conflict with the needs of
individuals. Decisions are difficult when expensive treatment produces very
little clinical benefit. For example, it may do little to improve the patient‟s
condition, or to stop, or slow the progression of disease. Where it has been
decided that a treatment has a low priority and cannot generally be supported,
a patient‟s doctor may still seek to persuade the PCT that there are
exceptional circumstances which mean that the patient should receive the
treatment.


6. POLICY DRIVERS
The Department of Health issues guidance and directions to NHS
organizations which may give priority to some categories of patient, or require
treatment to be made available within a given period. These may affect the
way in which health service resources are allocated by individual PCTs. The
Policy Group operates with these factors in mind and recognise that their
discretion may be affected by National Service Frameworks, NICE technology
appraisal guidance, Secretary of State Directions to the NHS and
performance and planning guidance.

Locally, choices about the funding of health care treatments will be informed




Date of issue: 2nd December 2009   Version 2.2
                                                                           - 28 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



by the needs of the PCT and these will be described in the Operational Plan.


7. EXCEPTIONAL NEED
There will be no blanket bans on treatment since there may be cases in which
a patient has special circumstances which present an exceptional need for
treatment. Each case of this sort will be considered on its own merits in light of
the clinical evidence.



Based on the South Central Ethical Framewor k Authors: South Central Pr ior ities
Support Unit Steering Gr oup . Date of Issue: 12th Febr uary 2008. Recommended to
NW PCTs by the NW Specialist Commissioning Group.




Date of issue: 2nd December 2009   Version 2.2
                                                                           - 29 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




                                   APPENDIX 1




                        Operational Policy




Date of issue: 2nd December 2009     Version 2.2
                                                                           - 30 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



                                   Effective Use of Resources
                                       Operational Policy

1        BACKGROUND

1.1      The PCT has a wide range of Service Level Agreements (SLAs) with
         approximately twenty NHS Trust and independent sector organisations for the
         delivery of services. These should meet the vast majority of health
         requirements. The need to refer outside of these should be the exception to
         the rule.

1.2      However, in a number of instances, new treatments/therapies will come
         forward following national evaluation, for which individual patient treatment
         funding might be legitimately sought. Similarly, a more specialised service
         may not be available within an existing SLA and a referral be requested
         outside of existing SLAs.

1.3      This protocol sets out arrangements for PCT consideration of requests for
         individual patient treatments, and to bring forward new treatments for
         consideration either to be included within or as exclusions to existing SLAs.


2        FUNDING REQUESTS - PROCESS

2.1      The appropriate recommendation will always be based upon the Effective Use
         of Resources Policy. The process will be administered by the Head of
         Continuing Health Care and Effective Use of Resources to whom all requests
         should be referred.

2.2      All requests for funding will be allocated a unique identifier and acknowledged
         within 3 working days. The acknowledgement will provide an outline of the
         process the PCT follows. The patients GP will also be informed (where they
         are not the main clinician).

2.3      Patient consent will be required to pursue relevant information.

2.4      Where details of exceptional circumstances are requested, the information will
         be submitted, in the first instance, by the main clinician involved in the
         patients care to the Head of Continuing Health Care and Effective Use of
         Resources.

2.5      All relevant primary, community and acute clinicians involved will be
         contacted to provide supporting information. The patient will also have the
         opportunity to provide a written statement to support the case.

2.6      Appropriate records will be kept of all correspondence and contacts (e.g.
         telephone calls, emails etc)

2.7      The Head of Continuing Health Care and Effective Use of Resources will
         take a decision based on an assessment of current policy and any stated
         exceptional circumstances.




Date of issue: 2nd December 2009         Version 2.2
                                                                                - 31 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT



2.8      In the event that there is no existing policy statement covering the
         treatment/procedure, the Head of Continuing Health Care and Effective Use
         of Resources will refer to an Individual Patient Request Panel that will be
         asked to make a recommendation.

2.9      The Effective Use of Resources Policy Group will be asked to ratify the
         decision and the Effective Use of Resources Policy amended accordingly.

2.10     The patient and practitioners involved in the process will be informed of the
         decision. The patient and the main clinician who initiated the request will
         have the right of appeal.

2.11     If after the decision additional evidence comes into light, the IPR Panel can
         re-consider the case.

2.12     Responsibilities are as follows:

                                                                      Responsible
                                    Action
                                                                     Committee/Lead
                  Approval and review of the Effective Use of     EUR Policy Group
                   Resources Policy
                  Administration of the Effective Use of          PCT Director of
                   Resources Policy                                Public Health &
                                                                   Health Strategy
                  Medical advice on the application of the        PCT Medical Director
                   Effective Use of Resources Policy
                  Addition of further procedures to the list of   Advice from the IPR
                   excluded or capacity-limited procedures         Panel with ratification
                                                                   of the EUR Policy
                                                                   Group


2.13     The decision to be reached on any application for individual patient treatment
         funding will be one of the following as a single episode, time-limited or
         continuous commitment:

             To approve in-year funding; or
             To defer funding to the subsequent financial year; or
             To agree funding for a limited number of procedures to be undertaken in
              any one year, and defer all other requests to subsequent years. Criteria
              will have to be established to ensure patients are seen in accordance with
              clinical priority and then chronological order based on longest waiters
              first; or
             To add the procedure to the list of excluded treatments thereby rejecting
              the request for approval; or
             To require the treatment to be provided from within an existing SLA

2.14     A record of all requests will be maintained and regular reports provided to the
         EUR Policy Group.




Date of issue: 2nd December 2009        Version 2.2
                                                                                 - 32 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




3        APPEAL PROCESS

3.1      Where a patient wishes to have the decision to decline funding reviewed, this
         request must be received in writing from the appellant/representative, along
         with the reason for the appeal. This should normally be received within six
         weeks of receipt of the PCTs decision to decline the request. In processing
         the appeal the PCT will ensure that its 18 week treatment commitment is not
         compromised.

3.2      The appeal will be heard by a panel, to be convened by the Director of
         Planning & Performance, to include:

             A Chair appointed by the PCT from amongst its Non-executive Directors
             Two non executive directors of the PCT
             Two appropriately qualified professionals

3.3      Additional professional advice may be sought from public health or from local
         consultants or relevant services as appropriate. No member of the panel will
         have had previous involvement in the consideration of the case or have any
         interest in the case.

3.4      The Panel will be convened to consider appeals made by a member of the
         public or their GP against the implementation by Tameside and Glossop PCT
         of its Effective Use of Resources Policy, in respect of:

             deferment of treatment until the new financial year
             appeals where a request for treatment has been refused on the basis that
              suitable treatment facilities exist within existing SLAs
             appeals where a request for treatment has been refused on the basis that
              the treatment is specifically excluded under the effective use of resources
              policy and exceptional circumstances do not apply

3.5      In addition, the panel may make recommendations on the use of funds for
         services not available through contracts or not normally available through the
         NHS.

3.6      Appeals will normally be heard within 28 working days except in cases of
         emergency. The outcome of appeals will be communicated in writing to the
         appellant.

3.7      Parties to the appeal will include

             The patient and or their GP
             Representative of the PCT (Chief Executive or Director of Finance)

3.8      The PCT will inform the parties that there will be a hearing and requesting
         within 14 days of the date of the request, copies of any further documentation
         which the party wishes to produce at the hearing and the name and office of
         any other person attending




Date of issue: 2nd December 2009      Version 2.2
                                                                                 - 33 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




3.9      The parties shall not rely on any facts or contentions or additional
         documentation, which have not been available to the PCT in making its
         original decision unless the Chair of the panel in consultation with panel
         members, gives his/her consent

3.10     The panel will hold an oral hearing except where both parties have confirmed
         in writing their willingness for the appeal to be determined in their absence,
         based on the documentary evidence.

3.11     The appeal will be heard to a standard agenda:

             The appellant or representative shall state their case in the presence of
              the representatives of the PCT.
             The representative of the PCT shall have the opportunity to ask questions
              of the appellant or representative
             The members of the appeal panel shall have the opportunity to ask
              questions of the appellant or representative
             The PCTs representative shall put their case in the presence of the
              appellant and representative.
             The appellant or representative shall have the opportunity to ask
              questions of the PCTs representative.
             Members of the appeal panel shall have the opportunity to ask questions
              of the PCT representative
             Any person attending the hearing for the purpose of giving specialist
              advice to the panel shall be admitted to the hearing and parties,
              representatives and panel members shall have the opportunity to put
              questions to them. They will then be released from the proceedings.
             The appellant or representative and the PCT representative shall have
              the opportunity to sum up their cases if they so wish. In their summing
              up, neither party may introduce any new matter.
             The panel may at its discretion adjourn the appeal in order that further
              information may be produced.
             The appellant, representative and the PCT representative shall withdraw
              and the panel shall consider the case in private.

3.12     If the parties have elected to wait, the panel‟s decision will be communicated
         to them verbally by the Chairman. The outcome will be confirmed in writing
         within 3 working days.

3.13     Appellants who are aggrieved at the panel‟s decision may access the PCT
         complaints procedure and submit a formal complaint about the process
         followed by the appeal panel

3.14     The outcome of individual appeals will not be reported to the PCT. The
         number of appeals will be highlighted as part of the ECR report to the PCT.

3.15     Policy recommendations will be made to the PCT for endorsement.




Date of issue: 2nd December 2009     Version 2.2
                                                                               - 34 -
NHS Tameside & Glossop: EFFECTIVE USE OF RESOURCES POLICY AND APPLICATION DOCUMENT




          Patient Consent Form - Effective Use of Resources
Please fill in this form to show you have agreed that we can ask for information about
you from the Doctors who are caring for you, which will help us to consider your request
for treatment.

Information we receive about you will be treated in the strictest confidence and its
use will be governed by the Data Protection Act. You can also enclose a brief written
statement explaining why you think you need this treatment and any exceptional
circumstances. You can ask a friend, relative or advisor to help you write this, if you
like. Please tick the relevant box below if you are enclosing a statement.



         I understand that Tameside & Glossop Primary Care Trust may need
     to request information about me for the purposes of making a decision about
            providing treatment under its Effective Use of Resources Policy.
                By signing thi s form, I am giving my consent to thi s proce ss.


Your name


Date of birth                                                      Sex (M/F)


Address


                                                             Postcode


Telephone


 I am enclosing a brief written statement outlining the relevant exceptional circumstances
of my case


Your signature                                                             Date



    Please return this form and your statement (if you are providing one) to:

                                             Michelle Rothwell
                                           Head of CHC and EUR
                                   Tameside & Glossop Primary Care Trust
                                          Mossley Health Centre
                                              Market Street
                                                 Mossley
                                                 OL5 0HE
Date of issue: 2nd December 2009            Version 2.2
                                                THA NK YOU                          - 35 -
                          APPENDIX 2




            Terms of Reference for
       Effective Use of Resources (EUR)
                  Policy Group




                                          36
Created by Gemma Voaden
          Effective Use of Resources (EUR) Policy Group
                      TERMS OF REFERENCE


   PURPOSE

   The EUR Policy Group will undertake two principal tasks:
     i. To prepare for the PCT‟s Professional Executive Committee (PEC) and Board,
         policies and procedures relating to the effective use of service commissioning
         resources, and;
    ii. To receive, advise and act upon new or unusual requests to commission services in
         accordance with the Effective Use of Resources Policies, utilising a separate
         Individual Patient Request Panel, and monitoring the activity of that panel.

 DUTIES

The Effective Use of Resources Policy Group will determine the range of services to be
   commissioned by the PCT based on several factors including cost effectiveness, evidence
   based and health intelligence, thus creating a list and rationale for all services
   commissioned and not commissioned by the PCT. To do this the Group will:

       1. Review the evidence where possible including existing expert groups and services;
          good practice guidelines (including NICE) and the monitoring information available
          utilizing the EUR Database.

       2. Ensure liaison between the effective use of resources work in Greater Manchester
          and the work carried out locally.

       3. Develop protocols and policies for the effective use of resources in line with those
          being developed across Greater Manchester for endorsement by the PCT‟s PEC
          and Board.

       4. Develop decision frameworks for use by commissioning staff, an EUR Administrator
          and an Individual Patient Request Panel (see Appendix 2) and review these
          frameworks on an annual basis.

       5. Review information based on its own work and that of an Individual Patient Request
          Panel and ensure the intelligence base it builds is linked to the wider business of
          the Organisation: -

                      To report and investigate as appropriate any clinical governance issues
                       that may arise to the relevant Directorate/Department/Group.

                                                                                                 37
   Created by Gemma Voaden
                   To report and investigate as appropriate any corporate issues that may
                    arise to the relevant Directorate/Department/Group.

                   To report and investigate as appropriate any commercial/contracting
                    issues that may arise to the relevant Directorate/Department/Group.

                   To report and investigate as appropriate any service/gap design issues
                    that may arise to the relevant Directorate/Department/Group.

    6. Identify potential areas for the development of a new policy or protocol.

    7. Monitor the financial implications of these decisions.

    8. Report activity on a bi-annually basis to the PEC.

    9. Ensure an Individual Patient Request Panel support the finance function by
       providing monthly financial updates.


FREQUENCY OF MEETINGS

This EUR Policy Group shall meet every two months.


MEMBERSHIP

Membership of the EUR Policy Group (Appendix 1)


QUORACY

The following members must be present for the meeting of the EUR Policy Group to be
quorate:

     Chair (or deputy)

     A minimum of two members registered with a clinical professional organisation

     A commissioning representative

     A Patient Advice and Liaison Service Representative

     A financial representative



                                                                                             38
Created by Gemma Voaden
  AGENDA SETTING

  The following items will discussed as standard at each meeting:

  a)    New service/therapy appraisals

  b)    Decision support frameworks and procedures, including:

  c)    Review of decisions made by an Individual Patient Request Panel, including

                 the range and nature of requests,

                 Patient experience / outcome

                 Financial Review

  d)    Horizon scan


REPORTING ARRANGEMENTS

  Minutes will be reported directly to the PCT‟s Professional Executive Committee (PEC).
  The EUR Group shall formally make a report to the PEC on a bi-annual basis detailing
  progress and monitoring information. Decision frameworks and EUR policies will be taken
  to the PEC for agreement then endorsed by the Board.



  Date TOR Agreed:

  Date for review of TOR:




                                                                                       39
  Created by Gemma Voaden
                                                                            Appendix 1


MEMBERSHIP of the Effective Use of Resources Policy Group



              Name                                Designation
(Chair)                       Director of Public Health and Health Strategy
                              PCT Medical Director
                              Medical Director, Tameside Hospital FT
                              Chief Pharmacist, Tameside Hospital FT
                              Pharmaceutical Advisor
                              Director of Contracting and Performance
                              EUR Administrator
                              Director of Nursing & Provider Services
                              Head of Continuing Care and Nursing
                              Professional Executive Committee Representative
                              Consultants in Public Health
                              Mental Health Lead Commissioner
                              PBC Representatives
                              Senior Commissioning Manager – Mental Health
                              and Learning Disabilities
                              NICE Manager
                              PALS Representative
                              Patient and Public Involvement Representative
                              Finance Representative
                              Chair of Greater Manchester EUR Group
                              (Standing Invitation)

Members are expected to send a representative who has been fully briefed if they
are unable to attend any meetings.

Other members will be co-opted as required.




                                                                                    40
Created by Gemma Voaden
                                                                                 Appendix 2

                      Individual Patient Request Panel (IPR Panel)
                                  Terms of Reference


PURPOSE AND DUTIES

 Individual Patient Request Panel

 PURPOSE

 To act as a decision-making body for requests to commission individual patient services
 which are either new or unusual, or fall outside of existing contracting arrangements and to
 manage them in a robust, objective, systematic and timely manner. To achieve this the
 Panel will:

 DUTIES

 1.    Review all requests for patient service funding received by the PCT

 2.    Make an assessment of the requests and reach decision using the frameworks
       provided by the EUR Policy Group and based upon a minimum level of supporting
       intelligence to include:

               A clinical referral letter
               A completed Patient Consent Form
               Minimum demographic details
               Relevant clinical history of the patient
               Diagnosis/Prognosis by referring clinician
               Any relevant additional health intelligence, and;
               Any relevant evaluation providing extenuating          circumstances       (e.g.
               psychological distress).

 3.    Assess the information received within 3 working days and reach a decision as to
       whether the case is to be approved, rejected or requires further information.

 4.    Set up a system for tracking and monitoring the outcomes of these decisions and to
       feed this information into the broader commissioning processes.

 5.    Monitor the financial implications of these decisions utilizing the EUR Database.




                                                                                             41
 Created by Gemma Voaden
  6.       Report activity on a bi-monthly basis to the EUR Policy Group, informing them of
           decisions reached, number of cases, etc.

  7.       Support the finance function by reporting into the monthly Financial updates.

  8.       Highlight to the EUR Policy Group any potential areas for the development of new
           policies or protocols.




  FREQUENCY OF MEETINGS

  The Individual Patient Request (IPR) Panel shall meet as and when required at a maximum
  of fortnightly intervals.


  MEMBERSHIP

  Membership of the IPR Panel (Appendix 3)


  QUORACY

  The following members must be present for the meeting of the IPR Panel to be quorate:

           Chair (or deputy)
           Minimum of 1 member registered with a clinical professional organisation
           A commissioning representative


REPORTING ARRANGEMENTS

  The IPR panel shall report to the full EUR Policy Group meetings.



  Date TOR Agreed:
  Date for review of TOR:




                                                                                           42
  Created by Gemma Voaden
                                                                           Appendix 3

MEMBERSHIP of the Individual Patient Request Panel

               Name                               Designation
                               Medical Director
                               Head of Continuing Care and Nursing
                               Consultants in Public Health
                               Mental Health Lead Commissioner
                               PBC Representatives
                               – ensure there is NO conflict of interest
                               Senior Commissioning Manager – Mental Health
                               and Learning Disabilities
                               In attendance:
                               EUR Administrator
                               Finance Representative
                               Associate Director of Contract Management,
                               Procurement and Performance

 A minimum of 3 members must be in agreement for an Individual Patient Request

 Panel must meet fortnightly with a minimum of 3 members present.




                                                                                   43
 Created by Gemma Voaden
         Appendix 4
                                                                                                                                START


                                                                    EUR Referral Management
Operational Process                                                                                                         REFERRAL
                                                                       EUR Decision Pro cess                                                                                                       Policy / Governance Process


                                                                                           Is the ser vice c overed by a c ontract, or available to
                                                                                           patients bas ed on 'free choice' of provi der?




                                                                              DON'T KNOW                          NO                       YES



                                                                          Contact the PCT's               Is it the PCTs                PROCEED
                                                                          ABC serv ice; or                policy to                     WITH
                                                                          Look on the PCT                 commission                    REFERRAL/
                                                                          website                         the serv ice?                 TREATMENT
                                                                          NB: facilities to be
                                                                          put in place




                                            DON'T KNOW                                 NO                                                                                YES                          THE PCT H AS NO T FORMUL ATED A POLICY


                                                                       Is a ref erral being                                                                    Rev iew critically why the ref erral has reached
                                                                       proposed with                                                                           this stage because it is actually policy to
                                                                       extenuating                                                                             commission the serv ice
                                                                       circumstances?


                                                                                                                                                                                             Is the ref erral so clinically urgent and the
                                            NO                                  YES                   Make application to PCT Indiv idual                                                    outcome so clearly benef icial to the patient that a
                                                                                                      Patient Request Panel; to include:                                                     decision is required bef ore the PCT has time to
                                                                                                      ref erral letter from ref errer                                                        undertake a health economic appraisal and
                                                                                                      patient consent f orm and                                                              make a policy recommendation to it's PEC?
                                                                                                      demographics; clinical history ;
                                                                                                      diagnosis; prognosis;
                                                                                                                                                                  YES                              NO
                                                                                                      health intelligence and ev idence
Ref errer to obtain and                        DO NOT REFER                                           supporting extenuating circumstances
supply relev ant                               - No
extenuating clinical                           commissioner                                                                                                    AND                                 Ref er to Director of Public Health and
intelligence and                               support                                                                                                                                             Health Strategy and Public Health to direct
ev idence in support of                                                                                                                                                                            economic appraisal locally and/or through
the ref erral. E.g.                                                                                                                                                                                the DsPH Network (EUR Administrator or
                                                                                                                     Panel receiv e
Psychological /                                                                                                                                                                                    Consultant in Public Health to carry out task
phy siological                                                                                                       inf ormation and make
                                                                                                                     assessment within 3                                                           if EUR Policy Group ref ers to DsPH)
assessments v ia PCT
                                                                                                                     working day s of receipt
procured serv ice
                                                                                                                     of the abov e lev el of
                                                                                                                                                                                                   Ref er outcome to PEC/Board f or
                                                                                                                     inf ormation                                                                  policy endorsement; to include
                                                                                                                                                                                                   also recommendations on
                                                                                                                                                                                                   contracting f ramework
                          Consider ref erral to CBT and other alternativ es
                                                                                                  Seek more                     REJECT
                                                                                                  inf ormation                  Adv ise patient       APPROVE                    AND               Update:
                                                                                                  f rom ref errer or            and ref errer,        Adv ise patient                              Policy documentation; website;
                                                                                                  expert adv isors              with details of       and ref errer to                             adv ice to PBC'ers, ref errers and
                                                                                                                                appeals               proceed with                                 Prov iders; SLAs
                                                                                                                                procedure             ref erral/
                                                                                                                                                      treatment


                                                                                                                                                                                            44
         Created by Gemma Voaden
   Appendix 5



          Operational Process

          The process for collating the requisite physiological and psychological information
          prior to an Individual Patient Request Panel meeting.

                                                             Is a ref erral being
                                                             proposed with
                                                             extenuating
                                                             circumstances




                                           NO                                       YES


                                                                                          EUR Referral Management

                                                                                            EUR Decision Pro cess
               Ref errer to obtain and           DO NOT REFER
               supply relev ant                  - No commissioner
               extenuating clinical              support
               intelligence and
               ev idence in support of
               ref erral E.g.
               Psychological /
               phy siological
               assessments v ia PCT
               procured serv ice




EUR                                      Consider ref erral to CBT and other
Administrator to                         alternativ es
track case




                                                                                                                    45
Created by Gemma Voaden
           Appendix 6



                      EUR Referral Management Process                                                                 START

                      How the referral process works
                                                                                                                  REFERRAL




                                                                                        Is the ser vice c overed by a c ontract, or available to
                                                                                        patients bas ed on 'free choice' of provi der?




                                                                  DON‟T KNOW                      NO                                 Y ES




                                                     Contact the PCT's                  Is it the PCTs                               PROCEED
                                                     ABC serv ice; or                   policy to                                    WITH
                                                     Look on the PCT                    commission                                   REFERRAL/
                                                     website                            the serv ice?                                TREATMENT
                                                     NB: facilities to be
                                                     put in place




                                DON‟T KNOW                     NO                                                                                  Y ES

                                                                                     Make application to PCT Indiv idual
                                                                                     Patient Request Panel; to include:
Operational Process                            Is a ref erral being                  ref erral letter from ref errer
                                               proposed with                         patient consent f orm and
                                               extenuating                           demographics; clinical history ;
                                               circumstances?                        diagnosis; prognosis;
                                                                                     health intelligence and ev idence                                         Policy / Governance Process
                                                                                     supporting extenuating circumstances

                         NO                             Y ES


                                                                                                  Panel receiv e
                                                                                                  inf ormation and make
                                                                                                  assessment within 3
                                                                                                  working day s of receipt
                                                                                                  of the abov e lev el of
                                                                                                  inf ormation



                          Seek more                         REJECT             APPROVE
                          inf ormation                      Adv ise patient    Adv ise patient
                          f rom ref errer or                and ref errer,     and ref errer to
                          expert adv isors                  with details of    proceed with
                                                            appeals            ref erral/
                                                            procedure          treatment



                                                                                                                                                          46
         Created by Gemma Voaden
 Appendix 7


        Policy / Governance Process

    If the service requested IS supposed to be commissioned by the PCT then the Policy /
    Governance Process becomes active as the Request should already be provided.
                                                Is it the PCTs
                                                policy to
        EUR Referral Management
                                                commission
                                                the serv ice?
          EUR Decision Pro cess




                                  NO     Y ES                                                  THE PCT H AS NO T FORMUL ATED A POLICY




                                                     Rev iew critically why the ref erral has reached
                                                     this stage because it is actually policy to
                                                     commission the serv ice




                                                                                            Is the ref erral so clinically urgent and the
                                                                                            outcome so clearly benef icial to the patient that a
                                                                                            decision is required bef ore the PCT has time to
                                                                                            undertake a health economic appraisal and
                                                                                            make a policy recommendation to it's PEC?




                                       Y ES                      NO                   Ref er to Director of Health Strategy
                                                                                      and Public Health to direct economic
                                                                                      appraisal locally and/or through the
                                                                                      DsPH Network (EUR Administrator to
                                                                                      carry out task if EUR Policy Group
                                                                                      ref ers to DsPH)




                                                                                      Ref er outcome to PEC f or policy
                                                                                      endorsement; to include also
                                                                                      recommendations on contracting
                                                                                      f ramework




                                                                                      Update:
                                                                                      Policy documentation; website;
                                                                                      adv ice to PBC'ers, ref errers and
                                                                                      Prov iders; SLAs



                                                                                                                                                   47
Created by Gemma Voaden
 Appendix 8


        Finance Process

        The procedure for the processing of invoices.

                Invoice received
                                                   Log invoice onto
                                                   database (date
                                                   received, etc.) and
                                                   photocopy for file
                Check invoice against
                data held on database
                (cost, provider, program
                budget code etc)

                                                   Cont act patient to ensure all
                                                   went ahead satisfactorily



                Pass invoice to relevant
                budget holder for approval

                                                   Once invoice approved send
                                                   to finance for payment
                                                   Log onto dat abas e as having
                                                   been paid




                                                                                    48
Created by Gemma Voaden
   Appendix 9



        Case Management for EUR Referrals

               Receive request for patient service funding
               Ensure all requisite documentation accompanies the request prior to Individual
                Patient Review Panel Meeting
               Log all information on database for each individual file
               Ensure cost of procedure is accurate and a record kept
               After Panel meeting contact patient informing them of the decision and rationale for
                making said decision to include information about appeals procedure.
               Contact patient after procedure to ensure all went successfully. If not, why not?
               When invoice received check all details to those in file (cost, pati ent details, etc)
               Close case once invoice forwarded to finance and patient satisfied with outcome.




                                                                                                         49
Created by Gemma Voaden
     Appendix 10



Appeal Process

1.    Where a patient wishes to have the decision to decline funding reviewed,
       this   request     must    be   received     in   writing   from    the
       appellant/representative, along with the reason for the appeal. This
       should normally be received within 6 weeks of receipt of the PCT‟s
       decision to decline funding. In processing the appeal the PCT will
       ensure that its 18 week treatment commitment is not compromised.


1.      The appeal will be heard by a panel, to be convened by the Director of
        Public Health and Health Strategy, to include:

           A Chair appointed by the PCT from amongst its Non-executive
             Directors
           Two non executive directors of the PCT
           Two appropriately qualified professionals

2.      Additional professional advice may be sought from public health or
        from local consultants or relevant services as appropriate. No member
        of the panel will have had previous involvement in the consideration of
        the case or have any interest in the case.

3.      The Panel will be convened to consider appeals made by a member of
        the public or their GP against the implementation by Tameside and
        Glossop PCT of its Effective Use of Resources Policy, in respect of:

                     deferment of treatment until the new financial year
                     appeals where a request for treatment has been refused on
                      the basis that suitable treatment facilities exist within
                      existing SLAs
                     appeals where a request for treatment has been refused on
                      the basis that the treatment is specifically excluded under
                      the effective use of resources policy and exceptional
                      circumstances do not apply

4.      In addition, the panel may make recommendations on the use of funds
        for services not available through contracts or not normally available
        through the NHS.

5.      Appeals will normally be heard within 28 working days except in cases
        of emergency. The outcome of appeals will be communicated in writing
        to the appellant.


7.      Parties to the appeal will include




                                                                              12
Created by Gemma Voaden
                      The patient and or their GP, and or a carer, friend or
                       relative
                      Representative of the PCT (Chief Executive or Director of
                       Finance)

8.      The PCT will inform the parties that there will be a hearing and
        requesting within 14 days of the date of the request, copies of any
        further documentation which the party wis hes to produce at the hearing
        and the name and office of any other person attending

9.      The parties shall not rely on any facts or contentions or additional
        documentation, which have not been available to the PCT in making its
        original decision unless the Chair of the panel in consultation with panel
        members, gives his/her consent

10.     The panel will hold an oral hearing except where both parties have
        confirmed in writing their willingness for the appeal to be determined in
        their absence, based on the documentary evidence.

11.     The appeal will be heard to a standard agenda:

                   The appellant or representative shall state their case in the
                    presence of the representatives of the PCT.
                   The representative of the PCT shall have the opportunity to
                    ask questions of the appellant or representative
                   The members of the appeal panel shall have the opportunity to
                    ask questions of the appellant or representative
                   The PCTs representative shall put their case in the presence
                    of the appellant and representative.
                   The appellant or representative shall have the opportunity to
                    ask questions of the PCTs representative.
                   Members of the appeal panel shall have the opportunity to ask
                    questions of the PCT representative
                   Any person attending the hearing for the purpose of giving
                    specialist advice to the panel shall be admitted to the hearing
                    and parties, representatives and panel members shall have
                    the opportunity to put questions to them. They will then be
                    released from the proceedings.
                   The appellant or representative and the PCT representative
                    shall have the opportunity to sum up their cases if they so
                    wish. In their summing up, neither party may introduce any
                    new matter.
                   The panel may at its discretion adjourn the appeal in order that
                    further information may be produced.
                   The appellant, representative and the PCT representative shall
                    withdraw and the panel shall consider the case in private .

12.     If the parties have elected to wait, the panel‟s decision will be
        communicated to them verbally by the Chairman. The outcome will be
        confirmed in writing within 3 working days.

                                                                                 13
Created by Gemma Voaden
13.     Appellants who are aggrieved at the panel‟s decision may access the
        PCT complaints procedure and submit a formal complaint about the
        process followed by the appeal panel

14.     The outcome of individual appeals will not be reported to the PCT. The
        number of appeals will be highlighted as part of the ECR report to the
        PCT.

15.     Policy recommendations will be made to the PCT for endorsement.




                                                                           14
Created by Gemma Voaden