Folder Service Restriction Policies
The purpose of our Service Restriction Policies is to ensure that West Essex Clinical Commissioning Group (WECCG) fund treatment only for safe, evidence based, clinically effective interventions and services delivered to the right patients.
Our service restriction policies cover a number of interventions and services that WECCG do not routinely fund. Patients should only be referred for the interventions and services listed in this policy if they meet the eligibility criteria set out in the service restrictions policy.
Interventions and services not currently commissioned through established care pathways or identified for funding through the commissioning process are not routinely funded.
The onus is on the clinician to ensure that appropriate authorisation from WECCG is accessed. Authorisation will be achieved either by prior approval or, where there are significant numbers of procedures, by retrospective audit (as agreed per provider) to assure compliance with criteria. The clinician must provide sufficient information to evidence how the patient meets the criteria.
WECCG will not pay for interventions or services in following circumstances -
- If a provider undertakes one of the interventions contained within these policies that requires prior approval and has not gained approval
- If a provider undertakes one of the interventions contained within these policies that requires retrospective audit and is found not to meet the criteria when the audit is undertaken
- If a provider undertakes an intervention that is not normally funded without gaining funding approval via an individual funding request
WECCG does not fund services covered by the NHS England Specialised Commissioning Group.
Types of service restriction policies -
Threshold Approvals – Those procedures which are commissioned by West Essex CCG on a routine basis but only for patients who meet the defined criteria set out within this policy but for which individual prior approval is not required. CCG notification of compliance or audit will be required according to contractual arrangements.
Individual Prior Approvals - Those procedures which are commissioned by West Essex CCG but only for patients who meet the defined criteria set out within this policy and which require individual approval on a patient by patient basis. For these procedures, the criteria listed form guidance to both the referring and treating clinicians and if a patient is deemed to meet these criteria prior approval should be sought from the funding team at the CCG.
Not Normally Funded – Those procedures which have been assessed as treatments of low clinical effectiveness by West Essex CCG and which will not be funded unless there are exceptional clinical circumstances. Applications for funding for these procedures can be made to the Individual Funding Request Team but should only be made where the patient demonstrates true clinical exceptionality (see below for definition of exceptionality).
Individual Funding Requests - West Essex CCG always allows clinicians the opportunity to make specific funding requests via its individual funding request process.
Policy development is an on-going process in response to evidence published. If an intervention is considered appropriate for routine funding there is an annual process to agree these within the contracts of providers.
Exceptional clinical circumstances refers to a patient who has clinical circumstances which are outside the range of clinical circumstances presented by a patient within the normal population of patients with the same medical condition and at the same stage of progression as the patient.
There are 2 tests to apply to exceptionality –
Test 1 – Is the patient is significantly different to the general population of patients with the condition in question wanting that intervention
Test 2 - the patient is likely to gain significantly more benefit from the intervention than might be normally expected for patients with that condition wanting that intervention.