Shaping better health
REMEDY : BNSSG referral pathways & Joint Formulary

About the EFR Service

Checked: 27-07-2020 by vicky.ryan Next Review: 26-07-2021

Overview

Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (BNSSG CCG) is responsible for making the best use of the NHS budget allocated to us for our population’s health services.  The demand for these services is always greater than the money available, so we have to prioritise the use of funds carefully.

To help us do this, we use national and local policies to ensure that the treatments, operations or drugs (interventions) we commission have a proven benefit in meeting the health needs of the population.

This means we will not routinely fund interventions that provide only limited benefit. Nor will we routinely fund unusual or uncommon treatments.

All  policies are developed with the support of clinical specialists in their field of expertise and go through a robust evaluation process before being adopted by BNSSG. The group responsible for evaluating these policies is known as the Clinical Policy Review Group (CPRG) and members meet quarterly.

You can access policy information using the List. Links take you to the policy information and application form on BNSSG CCG site. 

Clinical Policy Review Group (CPRG)

All policies are developed with the support of clinical specialists in their field of expertise and go through a robust evaluation process before being adopted by BNSSG. The group responsible for evaluating these policies is known as the Clinical Policy Review Group (CPRG) and members meet quarterly

All policies are reviewed every 3 years or earlier if clinical guidance / NICE publish new information.

The timescale between identifying a change in a policy or developing a new policy can vary but is around 6 months due to the research required and robust clinical evaluation process we are required to follow.

All policies fall into one of the following referral pathway routes;

  • Criteria Based Access (CBA)

    This means the CPRG members have approved funding for all patients who meet the published / agreed clinical criteria. If a patient meets this criteria no application form is needed. Referrers can refer directly, explaining how the patient meets the criteria. As a team we need this information as we audit CBA referrals twice a year and need to ensure the policy is being fully adhered to. 

  • Prior Approval (PA)

    This means the CPRG members have approved funding for all patients who meet the published / agreed clinical criteria. The EFR team have developed a matching PA Application form as a “checklist” of the policy.  

    • For All Bristol GP Practices:  This form needs to be submitted to the EFR Mailbox, along with the clinical information to support / evidence that the patient meets the criteria set out within the policy. By using the correct application form this walks you through the policy and ensures that you are reviewing the patient against the most current policy.  When you submit a Prior Approval application, the EFR team can make a decision on this quickly if all the information is supplied.
    • For All North Somerset GP Practice and those South Gloucester GP Practices who refer via the Referral Service:  This form needs to be included, along with the clinical information to support / evidence that the patient meets the criteria set out within the policy and the standard referral letter, when you submit a referral to the Referral Service via the usual e-Referral route.  By using the correct application form this walks you through the policy and ensures that you are reviewing the patient against the most current policy.  When you submit a Prior Approval application, theReferral Service can make a decision on this quickly if all the information is supplied. 
    • For those South Gloucester GP Practices who do not refer via the Referral Service:  This form needs to be submitted to the EFR Mailbox, along with the clinical information to support / evidence that the patient meets the criteria set out within the policy. By using the correct application form this walks you through the policy and ensures that you are reviewing the patient against the most current policy.  When you submit a Prior Approval application, the EFR team can make a decision on this quickly if all the information is supplied.

       

  • Exceptional Funding Requests (EFR)

    This means the CPRG members have agreed that no funding is routinely available for this request.

    No policy exists as the request is non- standard. 

    The patient does not meet the CBA / PA criteria but funding is still being requested.

    EFR applications require evidence of clinical exceptionality and without this all cases will be rejected/ not funded. 

    When the EFR Team feel they have received sufficient information – based on experience and previous case examples – the case will be passed to the Chair of the EFR Panel. EFR Managers meet with the Chair of the EFR Panel weekly to review these cases. The Role of the Chair is to triage the case and evaluate how to proceed. If a decision can be made - through delegated authority from the IFR Panel members - then this is done. The Chair may refer the case to the EFR Screening Group. It is the role of the Screening Group to filter out applications which are not appropriate to be put before the EFR Panel because the case should be determined through another process or where there is insufficient evidence to support the case on grounds of Clinical Exceptionality or Rarity. In all cases, it is not the role of the Screening Group to decide the merits of the case for Clinical Exceptionality or Rarity put forward by the Referring Clinician, only to check that evidence for such a case has been provided, as part of the application, for consideration by the EFR Panel. If a case progresses to an EFR Panel a letter will be sent advising of the date when the case will be considered. If a decision is made - through delegated authority from the EFR Panel members - then this is done. This decision can be approved / decline or deferred for more information. 

Frequently Asked Questions

What does Clinical Exceptionality mean?

This is difficult to define as by its very nature it is exceptional. As a team, we are looking for information which explains why you feel that your patient should be considered for funding approval over and above all other patients in the BNSSG area.

For a case to be considered as clinically exceptional we are looking for information which will identify your patient is significantly different from the general population who may also be affected by the same condition. We must also understand how your patient is likely to gain significantly more benefit from the requested treatment than would be generally expected.

There must also be evidence of the effectiveness of the treatment in relation to the condition.

It is the responsibility of the Clinical Referrer to present to case for exceptionality from a clinical perspective. Patient information add value and depth to a request, however it is the clinical exceptionality that is being requested.

Example of items not considered in isolation to be clinically exceptional

  • Patient has self-funded a treatment with benefit and now would like NHS funding

  • Patient has moved area and has previously received NHS funded treatment

  • Patient is more insistent than most

  • Patient is emotionally distressed by condition and would like funding

  • Patient is unable to maintain activity levels

  • Patient is young

  • Patient is elderly

  • Patient is pleasant

  • Patient unable to afford treatment privately

Significant Functional Impairment – SFI’s

This is a health community definition and is used in policies to get the patient’s experience of a condition.

Where this box is ticked in an application form, we require a supporting letter from the patient. This can be in any format. If we don’t receive anything with the initial referral, we will review and where appropriate we will send a letter to the patient directly asking for information. The case is then placed on hold until we hear back from the patient.

The information we are looking for when we send out a request for SFI’s is to understand how the condition is preventing the patient from functioning.

Statements advising us that patients can “do all required activities”, or that the condition is “bothersome” are unlikely to evidence that SFI’s have been met.

We do adjust the examples of SFI’s required dependent on the age / role of the patient. i.e we would consider if a condition is impacting a child’s ability to play as this is part of their normal development requirements and therefore would expect to see different information supplied compared to that of a working age adult.

Primary Care Receords– PCR

The EFR Team members only have access to the information you send through. We have no access to patient records, therefore if your application mentions an entry within your consultation – unless we receive a copy from you we can’t confirm this. Examples of this are when requesting a tonsillectomy and we are advised the patient meets the number of episodes criteria. However, unless we see a copy of the consultation records we can’t confirm this and have to delay the decision whilst we send an email back to the referrer’s team asking for the consultations.

When we send an email we may ask for a copy of the PCR, what we are looking for is any /all clinical information relating to the request.

EFR Panel

The EFR Panel meets monthly to discuss cases that the EFR Screening Group has triaged as appropriate for consideration. Panel members include Public Health Evidence Researchers, Medicines Management, Clinical Representation, Lay Member and where appropriate on a case by case basis Mental Health Commissioners and Children’s Commissioner.

Case files are prepared and shared in the week leading up to the meeting with all Panel members to allow the Panel members to review the information in advance. Number of cases considered at a monthly meeting vary and can be as high as 15 – 20 requests in one sitting. The role of the EFR manager is to minute these meetings and give consistency in line with the published process. Where a patient has called the EFR team and shared verbal information relevant to the request, the EFR Manager is there is convey this clearly to the EFR Panel members.

The EFR Manager is a non- voting member within the EFR Panel structure.

Following the EFR Panel meeting, minutes are written and once the Chair of the EFR Panel agrees, letters sharing the Panel outcome are produced and emailed to the Referring Clinician.

Top Tips

  • Read the policy to ensure you are considering your patient against the most up-to-date published policy.

  • Fully complete the application form

  • Ensure the EFR team are sent copies of the relevant consultations / clinic letters to support your application

  • If applying for SFI’s get a statement from the patient – or be aware of the delay whilst we request this

  • Photographs can and do help – they must be in colour.

  • If the patient doesn’t meet the CBA criteria, please explain clearly which criteria your patient fails to meet as requested in Q2.

  • If the patient doesn’t meet the CBA/ or PA criteria, please tell us why you feel your patient is clinically exceptional. Why they should be funded over and above all others

  • Email the applications to the mailbox – this is secure and allows us to have an audit trail of the request.

  • Use EMIS to prepopulate the forms

  • Complete electronically – handwritten forms are sometimes very difficult to read.