Clinical Funding Authorisation Policy

The Isle of Wight Clinical Commissioning Group (IW CCG) has a responsibility to seek the greatest improvement in the health of the Island’s population using the finite resources in terms of financial envelope, personnel and appropriate space and equipment available. This can lead to difficult choices having to be made in terms of competing priorities for investment and funding for treatments.

As a result the IW CCG has put in place a Clinical Funding Authorisation Policy for treatments that are not routinely commissioned or have restrictions in place in terms of clinical criteria. The clinical criterion has been established across the Wessex region by the Southampton, Hampshire, Isle of Wight and Portsmouth (SHIP) Priorities Committee, thereby ensuring a consistent approach across our regional partners.

A full list of the in-scope procedures and forms (appendix 5) can be found here.

The objective of this policy is to ensure that the finite financial envelope and resources available are utilised in the most cost and clinically effective way. The aim is not to stop or prevent a patient from having a treatment but rather to ensure that critical services are maintained. Whilst certain treatments are not routinely funded, it is essential to ensure they remain available for patients that meet the criteria or have an exceptional need for that treatment. For those patients that do not meet a criterion but can demonstrate an exceptional need, the IFR process is in place.

The clinical scope of this policy covers:

  • Adopted SHIP Priority Committee recommendations (Policy Statements)
  • Procedures of Limited Clinical Value (PLCV) including criteria based procedures and treatments that are subject to clinical thresholds and require prior authorisation
  • Non commissioned or cosmetic procedures (IFR only)
  • Drugs and devices outside of standard NHS National Tariff

Routine elective interventions are out of scope of this policy. These are treatments that are considered to be very well established and where evidence of effectiveness has not been called into question and those technologies that have already been recommended by National Institute for Health and Clinical Excellence (NICE) through a Technology Appraisal (TA).

Eligibility

  • The patient must be registered with an IW GP practice within the geographical responsibility of the IW CCG, or,
  • If not registered permanently and is not registered with a GP elsewhere in the country, lives within the geographical responsibility of the IW CCG. The ‘Who Pays’ the Responsible Commissioner guidance can be referred to and this can be searched readily on the Department of Health website
  • The provider would normally be expected to meet the CCG quality standards as per Care Quality Commission Standards
  • The procedure / treatment is not already purchased under existing service agreements. (Referrals for a second opinion should be made to an alternative provider with whom the IW CCG holds a service level agreement; if there is no second opinion SLA in place then the referring Clinician needs to submit an IFR.  Patient Choice guidelines will of course apply where relevant.)   

Private treatment

Treatment in the private sector will not generally be funded unless it is part of routine NHS provision through the Extended Choice Network. If a patient has opted to pay for treatment and / or interventions privately, these will not be funded retrospectively, this includes any future or continued treatment by the private provider.