On the Process for Obtaining Approval for Overseas Treatment Under E112

APPENDIX 4

POLICY & PROCEDURE

ON THE PROCESS FOR OBTAINING APPROVAL FOR OVERSEAS TREATMENT UNDER E112

(This document should be read in conjunction with the Powys tLHB IPC Policy date 23rd July 2008)

Rev / Date / Purpose of Issue/Description of Change / Planned Review Date
Adapted from Newport Local Health Board Procedure January 2007 and in accordance with WAG guidelines
Responsible Officer / Approved by / Date
Yvonne Jones
Planning and Commissioning Manager

POLICY & PROCEDURE PROCESS FOR OBTAINING APPROVAL FOR

OVERSEAS TREATMENT UNDER E112

INDEX OF CONTENTS

SECTION / DESCRIPTION / PAGE
1 / Introduction / 3
2 / General Principles / 3
3 / Procedure Detail / 4
3.1 / Consideration of requests by LHB Panel / 4
3.2 / Contacting Treatment Centre in Europe / 5
3.3 / Information required for E112 process / 5
3.4 / Confirm Support of the Local Health Board / 6
3.5 / Repatriation / 6
3.6 / Payment of Account / 6
4 / General Interpretation / 6
5 / Audit / 6
Appendix 1 / Department of Health Policy regarding E112 referrals / 7
Appendix 2 / Press Release Yvonne Watts v Bedford PCT / 12
Appendix 3 / Check List / 15
History and Approvals / 17

1 INTRODUCTION

This procedure is to be used to process requests for overseas treatment, via the E112 process, for pre-existing medical conditions. It applies to all officers involved in the receipt and processing of any such requests.

This procedure has been developed in accordance with the teaching Local Health Boards Standing Orders and Standing Financial Instructions.

This procedure should be read in conjunction with tLHB Commissioning Policy and Procedure for Individual Patient Commissioning.

2 GENERAL PRINCIPLES

The E112 process has been set out by the Department of Health and adopted by the Welsh Assembly Government to provide a clear process for patients who wish to have treatment in a country in the European Union other than the

United Kingdom. This policy sets out the principles against which applications for funding of treatment abroad will be considered, and the procedure that will be followed to process that funding should approval be granted. In order for funding to be made available for patients travelling abroad for treatment, authorisation must be sought before receiving treatment. The specific treatment required should be identified in the initial request and prior authorisation is required for any deviation from the intended treatment.

The policy adopted by the tLHB on its establishment in April 2003 has beenreviewed and updated to take account of the judgement of the European Courtof Justice on the application of Yvonne Watts v Bedford PCT and the Secretary of State for Health.

Under current arrangements, patients are entitled to seek NHS funding for treatment overseas under the E112 procedure that is described in the current

Department of Health Guidance (“Going to an EEA country or Switzerland in order to get treatment” ( And Guidance/ Health Advice For Travellers). This Guidance applies to England and Wales and will require review and amendment in the light of the decision of the European Court on

16th May 2006.

A Panel within the teaching Local Health Board will consider all requests (this will be the same panel which considers requests for Individual Patient Commissioning. The Panel will consider whether treatment is available locally and will also make an objective medical assessment of the patient’s medical condition, the history and probable course of their illness, the degree of pain they are in and/or the nature of his disability at the time of the request for authorisation. In order to do so the Panel will seek the guidance from the patients GP and/or UK Consultant.

This policy does not apply to any emergency treatment whether as an initial treatment or as a follow up for patients on holiday. It is the responsibility of residents to arrange sufficient travel insurance to provide for emergency healthcare whilst abroad.

PROCEDURE DETAIL

3.1 Consideration of requests by tLHB panel

In order to consider a request for funding to receive treatment in Europe, the tLHB will require the following information.

Information Required from GP:

• Patient Details (anonymised for panel)

• History of Illness

• Probable Course of Illness (including timescales)

• Degree of pain or symptoms (if any)

• Nature of disability (if any)

• How treatment centre was identified

• GP Opinion on reasonable waiting time for patient based on their clinical

findings.

• Why the patient cannot be offered treatment within this waiting time at the local service

In order that the panel can understand how the patient would continue to receive care if necessary following their return to the UK the GP should also include:

• Aftercare needs

• Contribution to aftercare arrangements

Information

Required from Consultant :

• Patient Details (anonymised for panel)

• Patients Condition/History of Illness

• Probable Course of Illness (including timescales)

• Degree of pain (if any)

• Nature of disability and severity of disability (if any)

• Patients Clinical Needs Now and During Probable Course of Illness

• Consultant Opinion on likely impact of treatment to address

patient’s clinical needs

• Consultant opinion regarding proposed treatment centre (if any)

• How treatment centre was identified

• Consultant opinion on reasonable waiting time for patient based

on their clinical findings

• Why the patient cannot be offered treatment within this waiting time at the

local service

• Aftercare needs

• Contribution to aftercare arrangements

The criteria for the teaching Local Health Board support are:

• An objective clinical assessment of the patient’s clinical needs.

• Where there is a waiting list that the waiting time for treatment within the local service exceeds the time that it is clinically acceptable for the patient to wait at the time of the request on the basis of the clinical assessment.

• There is no other NHS provider who can offer treatment to the patient within the time deemed appropriate based on the clinical assessment.

The tLHB will only consider funding for treatment for the patient.

Funding for carers travelling with the patient will not be considered.

3.2 Contacting Treatment Centre in Europe

The teaching Local Health Board will make contact with the suggested treatment centre in Europe to confirm:

• The estimated cost of treatment

• That the Clinician is willing to treat the patient

• That the hospital supports the E112 system

• Timescale for delivery of treatment

• Aftercare arrangements

• Any need for air ambulance home.

3.3Information required for E112 process

Should the request for funding be granted by the tLHB, the referral to

Europe will be made through the E112 process. The Department of

Health is responsible for co-ordinating the information and arranging for the issue of the E112. In order to approve E112 applications, the

Department of Health requires the following information:

• Referral from a Consultant in the UK to a Clinician in Europe;

•Letter of support from General Practitioner;

•Written support of Local Health Board confirming that they will underwrite the cost of treatment;

•Treatment commencement date and approximate duration of the treatment (E112 can only be issued for up to six months per episode of treatment)

•Written confirmation of aftercare arrangements.

3.4Confirm Support of the teaching Local Health Board

The criteria for teaching Local Health Board support are as follows:

• An objective clinical assessment of the patient’s clinical needs.

• Where there is a waiting list that the waiting time for treatment within the local service exceeds the time that it is clinically acceptable for the patient to wait at the time of the request on the basis of the clinical assessment.

• There is no other NHS provider who can offer treatment to the patient within the time deemed appropriate based on the clinical assessment.

Patients are entitled to appeal against any decision of the Panel via the teaching Local Health Boards Appeals Mechanism.

3.5Repatriation

Where a clinical need exists to bring the patient home as quickly as possible after treatment, costs for transport such as “Air Ambulance” over traditional travel will be considered.

3.6Payment of Account

The payment for treatment is processed through the Benefits Office in

Newcastle. The teaching Local Health Board underwrites the costs and they are deducted from any future allocations.

4 GENERAL INTERPRETATION

For further clarification or general interpretation, consult the Director of Public

Health or Medical Director who will advise on behalf of the senior management team.

5 AUDIT

Compliance will be subject to audit review.

APPENDIX 1

Going to an EEA country or Switzerland in order to get treatment

(Department of Health Policy)

The European Health Insurance Card (EHIC) is only valid for treatment that becomes necessary while you are abroad. Different rules apply if you go abroad specifically to be treated.

They are:

• the E112 referral system which covers maternity care and referrals for specific medical treatment

• some (limited) circumstances where patients may arrange and pay for hospital treatment abroad and reclaim some of the costs from their UK health care provider

The difference between the two systems is that the E112 arrangements provide treatment on the terms of the scheme in the country where treatment is provided (which may include a patient contribution to the costs) and the NHS pays the provider directly. The direct purchase method provides care up to the financial limits applying in the home state.

This is an evolving area of European legislation and practice in the United

Kingdom: you are therefore strongly advised to seek advice from your local health commissioner (Primary Care Trust in England, local health board in Wales or NHS board in Scotland or Northern Ireland) before proceeding - see below.

The E112 system

Under European Union Regulations, a system exists for referral to another

EEA country or Switzerland specifically for medical care. You will need a

Form E112 to show the foreign provider that you are entitled to such care.

The Department of Health, or its equivalent in Northern Ireland, is responsible for authorising the treatment abroad and, if appropriate, for issuing an E112, basing its decision on recommendations made by local health commissioners. E112s are not issued automatically or on a ‘just in case’ basis. There must be a clear need for treatment.

In deciding whether to recommend to the Department of Health, or its equivalent in Northern Ireland, that you are given an E112, your local health commissioner will need to be satisfied that:

• your UK NHS doctor – usually a hospital consultant - recommends that you be treated in the other country, and that a full clinical assessment has been carried out to demonstrate that the treatment will meet your needs;

• the costs of sending you abroad for treatment are justified against the local health commissioner’s responsibilities for spending money efficiently and fairly in the interests of all the patients it looks after;

• the treatment is available under the other country’s state health insurance scheme; and

• you are entitled to an EHIC.

Maternity care

There are special rules if you want to go to another EEA country (or Switzerland) specifically to give birth. You need to write to the Department of Health (or the Department of Health, Social Services and Public Safety in Northern Ireland) explaining why you want care outside the UK and enclose evidence from your GP or midwife of your due date.

Include your full address, National Insurance or NHS number, date of birth and dates of travel. You can also apply if you are not returning to the UK.

Rights to treatment under the E112 scheme

In some circumstances your local health commissioner must recommend that you are given an E112. This is in situations where you cannot obtain the treatment in the UK without undue delay and where the treatment is of a kind provided by the NHS and is justified. In considering what constitutes undue delay, the local health commissioner will take into account all the circumstances of your case, including, if appropriate, the degree of pain or the nature of your disability and whether this affects, for example, your ability to do your job.

How to apply for an E112

To apply for an E112, write to your local health commissioner explaining why you want to be treated outside the UK. Include a letter from your NHS consultant explaining why they are recommending treatment in another EEA country or Switzerland. If the local health commissioner agrees to pay for your treatment, it should forward both letters plus their recommendation to the Department of Health or its equivalent in Northern Ireland, who will decide whether to authorise the treatment and issue an E112.

Refusals to recommend treatment under the E112 system in another EEA country or Switzerland

Your local health commissioner will decide whether to recommend that you be treated abroad at public expense under the E112 system. If you think that you have the right to go abroad because of undue delay in your treatment and you do not agree with the decision of your local health commissioner, you can apply direct to the Department of Health. They will consider whether to authorise the treatment and issue the E112 even though the local health commissioner has not recommended it.

The Department will not judge the medical facts of the case: you will need to ask your local health commissioner for a second NHS medical opinion if you are unhappy with the first one you receive. The Department will normally deal with direct applications within 20 working days of receiving your letter. If you are not happy with the Department of Health’s decision, you can apply for a judicial review of the decision through the UK courts. You are strongly advised to seek legal advice if considering making an application for judicial review and should bear in mind that there is normally a three month time limit for doing so.

Other rights to go abroad for hospital treatment

In certain circumstances patients who go abroad directly for hospital treatment may be entitled to the payment of some of their costs by the NHS.

This follows from decisions by the European Court of Justice (ECJ) and our domestic courts on the circumstances in which a patient can be treated by providers in another EEA country directly outside the E112 procedure or NHS commissioned service. Normally, treatment in these circumstances means that you have to approach the provider yourself and pay for such treatment from your own resources before claiming reimbursement from the NHS retrospectively. As this is a complex area of developing law you are strongly advised to take your own legal advice and to seek advice from your local health commissioner before making any arrangements for treatment. If you go ahead without both a recommendation from your NHS consultant or other appropriate health professional and the agreement of your local health commissioner, you may find that you are subsequently unable to obtain reimbursement. You are also advised to check the Department’s website for any updating of this guidance.

In deciding whether they agree that you are entitled to the payment of some of your costs by the NHS, your local health commissioner will consider all the circumstances relevant to your case. Amongst the factors to be considered are:

• Whether treatment which is the same or equally effective can be obtained

without undue delay under the NHS; and

• all the circumstances of your individual case including, if appropriate, how much pain you are in, the nature of any disability and whether your condition is affecting your ability to work, as well as your medical history.

Requests for reimbursement should be made in writing to your local health commissioner. The rules for reimbursement are different from the rules under the E112 scheme. Public authorities are only required to reimburse what the NHS would have paid for the treatment. Where treatment abroad costs less than the cost in the NHS, you will not be reimbursed more than you pay.

There is no obligation to meet your travel or accommodation costs unless these costs would be met if you were being treated in the UK, e.g. because you were on income support. If you are unhappy with a decision on your claim for reimbursement, you can apply direct to the Department of Health. If you are also unhappy with the Department’s decision you may apply for a judicial review through the UK courts.

You should also bear in mind that the extension to tax-funded health systems such as the NHS of the ECJ case law on the rights of patients to go abroad and claim reimbursement is under challenge. This is therefore interim guidance and you should check the Department of Health website for updates.

Direct referrals for treatment

It is also possible that your local health commissioner may offer you treatment purchased directly from providers in other countries with whom they have established links. Not all local health commissioners offer this option.

APPENDIX 2