Why does the CCG need a set of principles?
The CCG holds the keys and the purse strings for the majority of local health services. It is responsible for commissioning a wide range of clinical services, including secondary (hospital), community and mental health services for your area and for paying for those services, for and on behalf of, the local population. In some areas this also includes commissioning primary care (GP services) alongside NHS England.
It’s guardianship of local NHS services needs to be done in an open, fair and transparent manner, but in so doing must take into account fully and responsibly, the management of the limited resources at its disposal. A set of agreed principles is vital to help the CCG meet its duties and responsibilities and to guide the clinical decisions made by both the CCG and the full range of clinical providers who deliver the healthcare it commissions.
Why does the CCG need a suite of clinical policies?
Having a set of agreed principles only goes so far in helping to make clinical decisions. Individual cases bring about specific issues that need greater detail and depth in order to allow equitable, practical and justifiable decisions to be made about the clinical treatment that should or should not be provided under the NHS.
Specific policies, based upon the set of principles, support the process of clinical decision making on a daily basis. Although still open to interpretation and judgment, policies provide a firm bedrock for decisions about services that can be recognised, understood and tested by all concerned; clinicians, commissioners, appeals panels, patients and other stakeholders.
CCGs are legally obliged to develop and publish the governance protocols it has established for decision making and the policies it has adopted to determine whether care and treatments are to be made available to the local population. As a significant proportion of clinical decisions fall within the remit of contracts or service level agreements between commissioner and providers (e.g. clinical commissioning groups and hospital trusts) the vast majority of clinical policies referred to in this document relate to decisions on procedures considered to be of low clinical value/priority.
What is meant by a governance framework?
As an organisation with responsibility for the expenditure of public money and the delivery of public services, a CCG must have a set of rules that governs what it does and how it does it. It must demonstrate integrity and solicitude in the decisions it makes. The governance framework, of which the principles and the clinical policies form a part, provides a legal and robust structure that both guides and protects the organisation and its members and gives meaning, reassurance and transparency to those (public, patients and others) who need to use and trust in its performance and decisions about their access to care and treatment.
Why review policies now?
It has always been a responsibility of CCGs (and predecessor PCTs) to review clinical policies on a regular basis. This is done to ensure that changes in best clinical/medical practice are taken into account, including National Guidance from NICE (National Institute for Health and Care Excellence) and other bodies. It also means updates as a result of new legislation or legal decisions can be made to existing policies. All policies have a review date, which is usually within two or three years of their adoption. Each CCG had policies due for review.
In addition, the individual funding request (IFR) process service provided by NHS Midlands and Lancashire Commissioning Support Unit applies the inherited policies of CCGs which were different from each other, some out of date and some up for review. This provided an ideal opportunity to review the policies across the CCGs, agree a common process for IFRs and increase the co-ordination of policies and services across Lancashire, making them more consistent and fair.
Which CCGs are involved?
All eight CCGs in Lancashire are involved. These are:
- Morecambe Bay Clinical Commissioning Group (which includes South Cumbria)
- Chorley and South Ribble Clinical Commissioning Group
- Greater Preston Clinical Commissioning Group
- West Lancashire Clinical Commissioning Group
- East Lancashire Clinical Commissioning Group
- Blackburn with Darwen Clinical Commissioning Group
- Fylde and Wyre Clinical Commissioning Group
- Blackpool Clinical Commissioning Group
Blackpool Clinical Commissioning Group run their own IFR process and are planning to review their policies in the near future but have joined in this review to help and inform this process and their own review.
Which policies are involved?
Each Clinical Commissioning Group in Lancashire has a range of clinical policies which varies from CCG to CCG dependent upon their local circumstances. It would be a long and arduous job to harmonise or replicate all these policies across all CCGs at the same time. A number of policies common to each CCG are being considered first. For example, each CCG had several policies relating to cosmetic procedures. It has been agreed to consolidate these into one Cosmetic Policy which replaces up to eight previous policies. Other common policies include:
Other common policies include:
|Assisted Conception||Dilatation and Curettage/Hysteroscopy||Policy for the Commissioning of Services for People with Erectile Dysfunction|
|Treatment of Varicose Veins||Policy for Surgical Release of Carpal Tunnel Syndrome||Policy for the Commissioning of Testing for Malignant Hyperthermia|
|Reversal of Sterilisation in Males & Females||Hip Arthroscopy||Surgical Management of Otitis Media with Effusion using Grommets in Children (under 12 Yrs)|
|Complementary and Alternative Therapies||Planned Caesarean Section||Procedures of Limited Clinical Value (Better Care Better Value — Lumbar Spine procedures)|
|Endoscopic Procedures on the Knee Joint Cavity||Photorefractive (Laser) Surgery for the Correction of Refractive Error||Epilepsy Assessment — In-Patient assessment using video telemetry or residential care for young children and young people with severe epilepsy|
|Male Circumcision||Spinal Cord Stimulation||Inguinal, Umbilical and Femoral Hernias|
|Tonsillectomy||Surgical Release of Trigger Finger||Functional Electrical Stimulation for foot drop of central neurological origin|
|Excision of Uterus|
Other policies may be added to this list as the process continues.
What is the review process meant to achieve?
The main purpose of the review is to deliver the following outcomes for the CCGs, and through them, clinicians and patients.
- Review historical PCT policies to ensure a consistent and fair approach to reduce the ‘postcode’ lottery that can result from having different policies across a geographical area.
- Develop a set of policies and principles against which to make these decisions.
- Determine procedures that the CCG will not commission either routinely or at all – because the procedure does not satisfy principles under which the CCG commissions services or because particular criteria need to be met for the intervention to satisfy the principles. These need to be set out and demonstrated prior to approval of funding
- Update policies in accordance with National Guidelines and best clinical practice.
- Ensure the limited and finite resources available for healthcare are prioritised according to the risks of mortality, disability, pain, poor health and damage to quality of life
- Develop collaborative policies across the eight CCGs in Lancashire.
What will this mean to patients?
The principles and policies under review guide the decisions made by CCGs about the care and treatment that will be made available to patients. This is in both what the CCG will commission and in what providers of services will be asked and paid to deliver. This has a direct impact upon the services patients and the public can expect from their local NHS services. For the majority of patients this will mean little or no change to the services they access now as they will continue to be delivered as part of the commissioner/provider contract. However, for some services, such as those mentioned in the table above, there may well be a change in the service provided or that a service is no longer provided at all on the NHS due to its low clinical value, poor or unproven patient benefit and prioritisation of resources.
This will also have a direct impact upon decisions made for individual funding requests, both in terms of the referrals that GPs and their patients will make and in the decisions that IFR panels will make about those referrals.
By having one harmonised set of policies, all patients who may require a procedure will have to meet the same criteria, wherever they live in Lancashire or South Cumbria. This ensures all patients are treated equally and that those who will benefit the most from the treatment will be able to receive it.
In cases where a patient will no longer be able to receive a treatment which they would previously been able to have, the patient will be supported by their GP to find alternative treatment which may be of greater benefit to them or in demonstrating they are an exception to the norm.
What impact will this have on individual funding requests?
An individual funding request can be made by your clinician (doctor or other health professional) if they believe that a particular treatment or service that is not routinely offered by the NHS is the best treatment for you, given your individual clinical circumstances.
Having the same or identical policies across CCGs will make the process for individual funding requests more streamlined, more efficient and reduce the likelihood of errors. There will be less confusion for both staff, patients and clinicians and the service will be more consistent, equitable and fair for the population across Lancashire and South Cumbria as a whole.
What are procedures of limited clinical value?
Some routine treatments are now described as ‘Procedures of Limited Clinical Value’ (PLCV). These are procedures which national experts have suggested have only limited or temporary benefit, and which are not felt to be necessary to maintain good health. However, it may also include procedures which are deemed to be effective but which will only be so when specific criteria, conditions and circumstances are met. This means they need to be considered on a case by case basis and meet strict criteria before they can be funded by the NHS.
The clinical policies developed by the CCG are often concerned with PLCV and identify the criteria that must be met, the effectiveness of those procedures in dealing with the health problem or concern and circumstances when the treatments will be funded.
A clinical policy identifies the treatment available on the NHS in the area covered by the CCG and must be followed by all clinical staff within the area, including GPs. However, if the treatment is not normally funded or the criteria is not met but your GP feels there are exceptional circumstances in your case and you would benefit from this treatment, then your GP can support you in submitting an individual funding request (IFR) on the grounds of exceptionality to the policy (see additional points on IFRs elsewhere in the Q and As).
Is this about saving money?
Yes and no. We believe that harmonising policies across Lancashire will help us to deliver more efficient and effective services. These services will be offered fairly and consistently across the area and be clinically appropriate. However, this exercise is taking place during a well-documented period of constraint for the NHS, which cannot meet the rising demands and expectations placed upon it without identifying priorities and making difficult choices.
A review of the procedures of limited clinical value or of lower clinical priority not only provides an opportunity to consider the latest evidence around effective and appropriate healthcare but also an opportunity to consider what can be afforded in the light of all the other services the NHS is expected to provide. There will be some cases therefore, when the decision may be partly or even mostly about the money.
Why do we need an Assisted Conception policy?
The NHS is primarily concerned with the treatment and care of patients who are ill or injured or who may have long-term physical and/or mental health needs that impact upon their general health and wellbeing. An inability to conceive or have children may or may not be clinical in origin but it is rarely linked to illness or injury and does not therefore, carry the same level of urgency and priority as some other NHS services. However, an inability to conceive can significantly impact upon the present and future general health and wellbeing of patients and, although of less a priority for NHS resources, there remain circumstances when it seems right to offer this service to patients. The Assisted Conception policy undertakes to determine under what circumstances and in which situations patients can expect to receive support from the NHS with conceiving and having children/a family.
I’ve seen reference to an IVF policy and an Assisted Conception Policy – what is the difference?
IVF (in vitro fertilisation) is a common and widely known method of assisting conception to take place, but it is not the only method available/used. IVF policies may concern IVF treatments only or they may be the name given erroneously to wider assisted conception policies. The new draft policy in Lancashire and South Cumbria is rightly referred to as an ‘Assisted Conception’ policy as it relates to various methods of helping patients to conceive not just IVF.
I’ve seen the draft Assisted Conception policy and it seems to be quite technical and complex – why?
The Assisted Conception policy, as with all the clinical policies that CCGs adopt, are legal documents as well as guides to decision making on areas of low clinical value. As such, the Assisted Conception policy needs to be a robust document that stands up to both legal and clinical scrutiny. There are a significant number of medical/clinical techniques involved in assisted conception services and these need to be correctly referenced in terms of purpose and terminology. This can make the policy appear complex and less easy for the lay-person to understand.