Nwl Clinical Commissioning Groups

NWL IFR Service

NWL CLINICAL COMMISSIONING GROUPS

PLANNED PROCEDURES WITH A THRESHOLD AND

INDIVIDUAL FUNDING REQUESTS

PROVIDER SERVICE SPECIFICATION

Service framework and guidance for providers in North West London for the application and service provision of Planned Procedures with a Threshold and Individual Funding Requests

Table of contents

Section 1 – Planned Procedures with a Threshold (PPwT)

1.1Planned Procedure with a Threshold – introduction to policy

1.2PPwT provider roles and responsibility

1.3PPwT authorisation process

1.4PPWT validation process

1.5.PPwT provider management report

1.6.PPwT audit process

1.7.PPwT key summary notes for providers

Section 2 – Individual Funding Requests

2.1Individual Funding Requests (IFR’s) – overview

2.2IFR Provider Role and Responsibility

2.3IFR key summary notes for providers

Section 3 - IFR/PPWT team roles and responsibilities

3.1IFR/PPwT Team - overview

3.2Role of the Director

3.3Role of the Associate Director for IFR

3.4Role of the Operational Manager – for IFR/PPwT

3.5Role of Clinical Advisor and Knowledge Manager Provide Clinical Leadership for the service

3.6Role of the Chief Pharmacist

3.7 Responsibilities of the Business Management/Administration team:

Appendix 1 PPwTindex sheet

Appendix 2IFR form

Appendix 3 Urgent IFR form

Foreword

The NHS North West London Individual Funding Request (IFR) and Planned Procedure with a Threshold Policy (PPwT) were established in April 2011. The policies are now part of the commissioning framework for North West London Clinical Commissioning Groups. The aim of Provider Service Specification is to provide guidance for providers to fulfil their contractual obligations in relation to continued operational implementation of the PPwT and IFR policies. The PSF should be used as a handbook of reference for providers and will be refreshed and updated periodically as appropriate throughout the year. The PSF has been updated to reflect changes to the PPwT policy for 2013/14 and refinements of any operational processes following discussion and agreement with providers, particularly around the audit and challenge process.

The provider as part of the 2013/14 contract has agreed to abide by the PPwT list (appendix1) and adhere to the commissioned thresholds within each procedure, where appropriate. The list clearly contains those procedures that are clinically-authorised (tick box forms) and those that require pre-authorisation through the IFR system. NWL CCG’s will not pay for any procedures that the provider has undertaken without the appropriate authorisation within the agreed timeline. NWL CCG’s will not agree any retrospective funding.

The service continues to be co-ordinated centrally. Key contact for clinical and operational enquiries is via email r phone 0203 350 4123.

Key messages re-iterated in the 2013/14 version include:

• PPwT timetable aligned to SUS challenge timetable and associated response timeline
• Where it is not clear from the commissioning dataset that a challenge raised is outside the scope of policy the onus is on the provider to validate and provide the relevant evidence.
• No authorisation form received within the scheduled timeframe, (late forms) no payment.
• Completion date on form is the decision to treat date, incorporating consultation, one-stop clinics and following follow-up tests.
• Re-iteration of the non-retrospective funding position
• Challenge validation using databases where agreed by Account Teams and production of PPwT reference number where no record of receipt of form can be evidenced by PPwT team.
• Re-iteration of recording thresholds in clinical notes, to demonstrate compliance during audits.
• Re-validation of general practice forms by providers
• In terms of IFR re-iteration that applications that affect a cohort of patients/population should be deemed as service developments and not IFR’s and should therefore be managed through the mainstream CCG commissioning cycle.

Section 1 – Planned Procedures with a Threshold (PPwT)

1.1Planned Procedure with a Threshold – introduction to policy

PPwT is part of the North West London Clinical Commissioning Groups (CCG) Effective Commissioning portfolio and is a clinically driven process whereby a clinician makes a decision whether a patient meets the evidence-based thresholds for treatment as defined in the PPwT Policy (Version 3 01.04.2013).The access for treatment is either through a clinical authorisation route (PPwT form), or through completion of an Individual Funding Request (IFR) form. For IFR’s the clinician would need to demonstrate clinical exceptionality as defined in section2. Appendix1 defines the route for each PPwT Intervention.

1.2PPwT provider roles and responsibility

PPwT pertains to elective care treatment pathways. Out of scope are:

• Procedures undertaken through a non-elective pathway
• Referrals made through cancer two week wait pathway
• Referrals that are upgraded to cancer pathway post out-patient consultation
• Any procedures upon validation post challenge it is agreed is out of scope of policy

Within the overall PPwT process the provider should be familiar and has agreed to adhere to the following scenarios:

• Where the GP has agreed the referral meets the criteria and completes a PPwT form, the provider must validate the form as part of the overall referral validation process and triaging, to ensure it is fully completed and send a copy to the central team. The central team will validate and ensure the boxes have been completed correctly. Although the PPwT forms are authorisation to treat, should any discrepancy be identified, the referrer will be contacted within 5 working days. It is the expectation that any re-submitted forms will need to be sent in within 15 days upon receipt of notification from the central PPwT Team. If this date is after SUS submission date, this may be raised as a challenge and will be refreshed the following month. . Acknowledgement/receipt that the forms are being logged as authorised is also sent within five days.
• Where the GP is uncertain of the definitive treatment plan and requires a specialist opinion, the patient should be seen for consultation. Once the provider clinician has established a PPwT may be necessary, it is the responsibility of the provider clinician to complete the PPwT form. A copy of the PPwT form should be sent to the central PPwT team (as per email address above) via a secure NHS Net account, as it will contain patient identifiable information. The date the decision to treat was made is the date that should be entered onto the PPwT form, not the original referral date. This is in acknowledgement that the decision to treat is often made, following out-patient attendance, one-stop clinic attendance, or following additional investigation.
• The referrer should ensure that there is sufficient evidence in the patient record to substantiate and support that PPwT criteria have been met. Providers must ensure that there is sufficient evidence in patient records to validate and support criteria even where the PPwT has been completed by the GP or another referrer. As part of a review process of the PPwT policy, regular audits will be carried to ensure that the protocols are implemented, appropriately and effectively. If, during audits, it is identified that the notes do not contain sufficient information to confirm thresholds, there may be a financial implication for the Trust as this may be considered to be activity that is not commissioned due to insufficient evidence.

• Where the patient either does not meet the criteria but there may be a case for clinical exceptionality, or for the cases that are defined on the PPwT Index Sheet to be reviewed on an exceptional basis, the provider clinician may complete the NWL CCG IFR Form (Appendix2). The forms are available on via the IFR website, or can be obtained by emailing

• Any incomplete (i.e. thresholds not fully completed) PPwT forms will be returned to the provider within five working days from receipt by the central office with the expectation as appropriate a re-submitted completed form within 15 days.

• Any forms received after the SUS deadline, will be regarded as late and therefore unauthorised activity. Providers will receive an email from the central team notifying them of this.

In summary, the PPwT form is the authorisation to treat and providers will not receive payment if one has not been completed and sent to the central team at the time the decision is made and within the scheduled timeframe. IFR forms however require pre-authorisation and, in some instances, will have to be presented to the IFR panel or decisions will be made at IFR triage within 28 days. Providers should always await the outcome of the IFR decision before commencing or advising patients of treatment. If however a case becomes clinically urgent, providers can treat at their own financial risk. IFR panel decisions are provided in 28 working days.

1.3PPwT authorisation process

The Clinical Commissioning Group (CCG) budget holder will only be obliged to reimburse providers that have carried out treatments covered by the PPwT policy if:

• appropriate criteria have been met,
• this is adequately recorded in clinical notes and,
• related form has been submitted prior to starting treatment by the agreed published deadline.

If a provider elects to provide such treatment without first obtaining an approval code (IFR’s) or completing and submitting a PPwT authorisation form at the time of decision to treat, then they do so at their own financial risk, even where it can subsequently be proven that the patient meets the PPwT criteria and would have been entitled to the treatment. North West London CCG’s do not fund retrospective funding requests under these circumstances.

Authorisation to treat will be either by:

• Receipt of a completed PPwT threshold form as part of a referral from general practice, which has been validated by the provider following decision to treat.

• The Provider Completing a PPwT threshold form following a decision to treat and a copy sent to the PPwT Central team. Just to re-iterate, the central PPwT team will validate and notify the referrer within 5 working days of any discrepancies and send an acknowledgement when forms have been logged and processed. Providers have 15 working days to re-submit relevant completed forms. Should this go past the monthly cutoff date, this may appear as a challenge, but should be reconciled as part of the challenge process – where valid forms will be revoked.

• To allow some flexibility - Providers can send the completed PPwT forms to the central team in specialty batches, as long as they are within the month-end timetable as defined below in table1. If forms are received after the dates within Table1 they will be classified as late submissions and therefore not included in the month end authorisation. This will be subject to challenge as unauthorised through the contracting process. Following the monthly defined submission date, the IFR central team will send all the activities handled in relation to IFR and the PPwT to NWL Commissioning Support Unit Information/Contracting Team. The PPwT applications held on the central database will be validated against SUS data for that reporting period.
• Any activity presented via SUS that does not have an authorised PPwT form and has been checked and validated as genuine PPwT activity, (as far as possible) will have a challenge raised against it.
• This process is supported by robust internal validation to remove any challenges that do not fall within the remit of the PPwT policy and any non-applicable procedures that share the same codes as PPwT policies – as far as the SUS commissioning dataset permits.
• It is recognised however that based on the commissioning SUS dataset, despite the validation it is not always possible to identify procedures that sit outside the scope of policy and have been challenged. It is for the provider to provide evidence that any challenge raised sits outside the scope of policy.
• Evidence can be via clinical notes or for cancer pathways/exemptions or via a database such as Open Exeter or other local cancer databases. Evidence can also be via clinical letters. Using a database for validation must be agreed with the Account Team as part of the formal response process.
• Providers are asked to produce a PPwT reference number where after validation checks the PPwT team have no record of receiving a form.
• As per other NHS NWL challenges, it will be the responsibility of the provider to produce the evidence that an authorisation form was accurately completed in the month the decision was made and before the submission deadline defined in table1, or that the challenge was not applicable.

1

Table1 PPwT Schedule 2013/14

1

1.4PPWT validation process

The PPwT authorisation process is run by the centralised PPwT team who validate all forms received by referrers, within the agreed specified five days, using four sub-processes (highlighted in the flow charts).

• Forms that are received on an individual basis
• Forms received in batches
• Late Submissions (as defined in table1)
• Incomplete thresholds

As stated previously North West London CCG’s will not accept any PPwT forms submitted late after the dates defined in table1 previously. The following flow charts highlight the processing of PPwT forms. Appendix3 also provides an example of the template letters sent to providers advising them on the status of the forms.

Generic PPwT process flow chart 1

PPwT batch process

PPwT batch late submission process flow chart 2

1.5. PPwT provider management report

Following feedback from providers, a monthly provider management report is produced that provides a summary of the forms received on a provider basis, by department and associated status. It is the expectation that this report will be used as a tool to provide central feedback, in recognition that the forms are sent logistically from a number of individual areas internally. This will be a reference tool only and cannot be used as a conduit for retrospective funding.

1.6. PPwT audit process

PPwT policy implementation will be supported by in year audits. The PPwT audit is intended to review PPwT practice at North West London providers with the aim of auditing compliance with the PPwT policies and learning lessons for improvement in process. There are two main areas of review:

• In cases where the provider has submitted a PPwT form - to audit that there is sufficient record in the notes to confirm the PPwT procedures have been carried out in line with agreed threshold recommendations (Part A)
• In cases where the provider has not submitted a PPwT form but the procedure has been identified by the commissioners as being within the scope of the PPwT policies - to assess the accuracy of the PPwT challenges (Part B)

Ad-hoc audits may be undertaken with mutual agreement where a need is identified e.g. over-performance, coding or challenges close down validation.

Part A

A sample of patient notes relating to approved PPwT procedures will be reviewed to

• To identify if PPwT procedures have been carried out in line with agreed threshold
• recommendations
• To confirm if IFR process is being followed.
• To audit that evidence relating to PPwT thresholds is recorded in the notes
• To identify PPwT procedure thresholds that may require review.

Part B

A sample of patient notes potentially relating to PPwT procedures will be reviewed to

• To determine whether the challenge is valid i.e. does the challenge relate to a PPwT procedure
• Where the challenge is not valid, to determine the root cause - e.g. coding, challenge scripts or the procedure cannot be identified from SUS data

Timing

Part A audit will be carried out on a twice a year. Dates will be agreed with providers. It is anticipated that audits will be undertaken in the following months.

Q1 and Q2 - December 2013 to Jan 2014Q3 and Q4- June 2014 to July 2014

Part B audits are expected to take place every quarter in order to close down challenges in a timely manner.

Q1 - September 2013

Q2- December 2013

Q3- March 2014

Q4- July 2014

Reports

The audits will report on:

• Compliance with PPwT thresholds for approved procedures
• Compliance with submission of forms for procedures challenged as being within the scope of PPwT policies

Commissioners will act on the findings of the audit within contractual frameworks. There may be financial implications for Trusts if it is found that audit standards are not met both for Part A and Part B

Communication with providers

A detailed audit framework will be agreed with providers at the beginning of the year, outlining detail such as sample size, selection of procedures to be audited and extrapolation agreement. The list of procedures will be agreed with providers for each audit. Providers are expected to nominate audit leads who will liaise with the NWL CSU audit team to put processes in place for audit.

1.7. PPwT key summary notes for providers

PPwT 2012/13 key notes:

Provider clinicians are expected to complete a PPwT threshold form to determine that a patient meets the criteria following a request for a specialist opinion.