Betsi Cadwaladr University Local Health Board ... - Health in Wales

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treatments or services that have not been approved by national guidance such as NICE, The Cochrane Centre or Public Health Wales or the All Wales Medicines Strategy Group, in order for funding to be agreed then there must exist an unusual clinical factor about the patient that suggests that they are Significantly different to the general population suffering from their clinical condition Likely to gain significantly more benefit from the treatment or service than the general patient population with the clinical condition The requesting clinician should highlight any case of exceptionality to the LHB when making the funding application. The following definition has been recommended for use in Wales 1 : Central to consideration of individual cases is the concept of the case being exceptional. The definition of exception is 'an instance that does not follow a rule'. There cannot therefore be 'rules' to guide decisions on exceptions; rather such rules would constitute criteria (policy) to provide the service. 1. In order for funding to be agreed there must be some unusual* clinical factor about the patient that suggests that they are i. Significantly different to the general population of patients with the condition in question ii. Likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition 2. The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exemption. 3. If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional. 4. It is for the requesting clinician (or patient) to make the case for exceptional status. 5. Social value judgments are rarely relevant to the consideration of exceptional status * The initial terminology was ‘unusual or unique’ but it is better to clearly differentiate unique from exceptional. 1 Adapted from UK Specialized Services Public Health Network 8 Comment [R1]: ? add definition here
Section 3 - Funding Application Procedures 3.1 The funding application process is in two stages. The core clinical structure of the LHB is based on Clinical Programme Groups (CPGs) and it is from within these groups that that the majority of funding applications will materialise. Recognising this, and the place of CPGs in being directly responsible for the delivery of care within their individual spheres of influence, applications in the first instance should be considered by the relevant CPG. Only applications considered and supported by the relevant CPG, and ‘signed off’ by the Chief of Staff, will be considered for funding by the LHB IPC Panel. 3.2 Requests for funding a treatment/service may be made by a GP, hospital Consultant or other health professional (the referring clinician). The LHB will not normally consider the request for funding from a GP or a short term locum consultant (who may not be aware of local services or procedures) direct to a specialist in other NHS organisations with which the LHB does not already hold a contract for that particular service, unless this has the support of the relevant CPG. 3.3 Self-referrals from patients will not be considered. Requests from patients and third parties (e.g. elected politicians) will be returned with the advice that the case should be discussed with the patient’s GP who should forward the request to a local secondary care consultant or other senior clinician with a view to discussion at CPG level. Referrals will not be accepted from a private clinician unless acting under contract with the NHS. 3.4 Prior to considering an application for Individual Patient Commissioning funding, the CPG will require an NHS Consultant or GP to carry out a full assessment of the individual patient’s needs and decide whether the treatment or service being requested is the most appropriate for the patient. 3.4.1 Before the request for funding can be considered by the CPG consideration will also need to be given to the clinical governance implications of the treatment – no funding request will be approved by the CPG where the clinical governance implications have not been addressed. Where a funding application is for a given drug evidence of approval from the BCUHB Drug & Therapeutics Committee (or sub committee at CPG level) will be required before support for funding is considered. 3.5 The request for funding must be made on the agreed request form (please see Appendix 2) with information about the following completed: The patient’s medical history An outline of the proposed treatment/service including an indication of the likely duration of the treatment 9
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Questions Comments / Explanation (m
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Has the application been approved b
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Date of IPC Panel For LHB Use Only
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Betsi Cadwaladr University Local Health Board ... - Health in Wales

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