PROTOCOL FOR THE MANAGEMENT OF:



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PROTOCOL FOR THE MANAGEMENT OF INDIVIDUAL PATIENT FUNDING REQUESTS:

❖ EXTRA CONTRACTUAL REFERRALS (ECR)

❖ National SpeciAlised SErvices

❖ JointLY fundED PackaGes of CARE

Date: 20 January 2010

Review & Amended Date: April 2011 – changes highlighted

Approved by: NHS Borders Board on 4 February 2010

Equality Impact Assessment Date: 20 January 2010

Contents

|Section 1 – Introduction and Definitions |3 |

|Section 2 – Ethical Framework |7 |

|Section 3 – Referrals Process and Funding Application Procedure |8 |

| A. Within working hours |8 |

| B. Outside working hours |10 |

| C. Additional process for children & young people and adults at risk |11 |

|Section 4 – Appeals Process |13 |

|Section 5 – Monitoring Arrangements |14 |

Appendices

Appendix 1 – Flowchart of ECR Procedure

Appendix 2 - Funding Application Form

Appendix 3 – NHS Borders Panel Decision Record Form

Appendix 4 – Eligibility for NHS Continuing Healthcare

SECTION 1 – INTRODUCTION AND DEFINITIONS

This document is based on the current guidance from the Scottish Government on establishing responsibilities for commissioning of an individual’s care within the NHS. The underlying principle is that no treatment should be refused or delayed due to uncertainty or ambiguity over which NHS body is responsible for funding an individual’s health care provision.

This paper presents the approach to be adopted by NHS Borders in managing requests for funding of patient treatments/services that fall within the following categories:

❖ Extra Contractual Referrals (ECR)

❖ Out Of Area Treatments (OATS)

❖ Unplanned Activity (UNPACS)

❖ National Specialised Services

❖ Jointly Funded Packages Of Care

DEFINITIONS

1. The Responsible Commissioner1

The most recent guidance from the Scottish Government is NHS HDL (2004) 15 “Guidance on establishing the responsible commissioner”. This guidance covers the following instances:

o Persons of No Fixed Abode

o Temporary Residents

o Patients who Move Cross Boundary (i.e. within Scotland)

o Placements in Care Homes

o Free Personal and Nursing Care

o Cross Border Patients

o People who Move Cross Border

o Out of Area Treatments: Cross Boundary & Cross Border

o Patients Transferred from the State Hospital

o Restricted Patients

o Early Discharge Protocol for Patients in Secure Hospital Settings

o Prisoners

o People Detained under the Mental Health (Scotland) Act 1984 or the Mental Health Act 1983

o Immigration Detainees

o Boarding School Pupils

o Schools & Colleges for Children/Young People with Special Educational Needs

o Looked After Children

o People Taken Ill Abroad

o Military Personnel

o People Not Ordinarily Resident in the UK (Overseas Visitors)

o Asylum Seekers

o Services Provided on an “All-Comers” Basis

o GUM Services and HIV/AIDS Patients

o Transplants

o Waiting Times Guarantees

o Transfer on Non-Clinical Grounds

The table below summarises the responsibilities of Scottish and English Commissioners:

|Patient resident in |Registered with GP in |Receiving treatment in |Responsible Commissioner |

|Scotland |England |England |Scotland |

|Scotland |England |Scotland |Scotland |

|England |Scotland |England |England |

|England |Scotland |Scotland |England |

1.2 Extra Contractual Referrals (ECRs)

Extra Contractual Referrals (ECR) relate to treatments/services not provided by NHS Borders locally or through a Service Level Agreement (SLA) with other NHS providers. Within the NHS ECRs are elective and typically represent low volume services and treatments (for emergency treatments see OATS and UNPACS below). They do not include specialised procedures which the National Services Division (NSD) has responsibility to fund, detailed later in paragraph 1.5. They are often provided by non-NHS health service providers, which can include nursing homes.

ECR funding is taken from current revenue allocations and therefore presents a potential in-year financial risk for NHS Borders. Prior approval for funding from NHS Borders must be sought before referral following the process outlined in Section 3. Approval is not automatic.

1.3 Out Of Area Treatments (OATS)

NHS MEL(1999)42 and NHS HDL(2002)393 set out the arrangements within the NHS for commissioning out of area treatments, both cross boundary and cross border.

OATS applies to NHS cross-border activity between Scotland and the other UK countries i.e. England, Wales and Northern Ireland. This covers emergency treatment only and therefore by its nature is unplanned and presents a potential in-year financial risk for NHS Borders. There is no right of refusal by NHS Borders as this is for emergency treatment.

Elective treatment within other UK countries falls into one of three categories:

• NHS Borders can agree explicit Service Level Agreements (SLAs) with the NHS in other countries for the provision of elective treatments to Borders residents. These are principally with the North Cumbria Acute Hospitals NHS Trust, Northumbria Healthcare NHS Foundation Trust and Newcastle upon Tyne Hospitals NHS Trust in England because of geographical access to services for some Borders residents.

• The National Services Division (NSD) of NHS Scotland commissions certain highly specialised and rare treatments on behalf of the whole Scottish population, see below for more details.

• All other elective treatments in other UK countries should be progressed through the ECR process and require prior approval before referral.

1.4 Unplanned Activity (UNPACS)

UNPACS (UNPlanned ACtivitieS) is similar to OATS but relates to emergency NHS treatments provided to Borders residents elsewhere in Scotland. Like OATS there is no right of refusal by NHS Borders as this is for emergency treatment. Funding is taken from current revenue allocations and therefore presents a potential in-year financial risk for the Board.

Elective treatment of Borders residents in other areas of Scotland fall into two categories:

• NHS Borders agrees explicit Service Level Agreements (SLAs) with the NHS in other Board areas – currently NHS Lothian and NHS Dumfries & Galloway for the provision of elective treatments to Borders residents. In the former this is for access to tertiary services and in the latter for geographical access for the population in the Newcastleton area.

• All other elective treatments in other NHS Boards should be progressed through the ECR process and require prior approval before referral.

1.5 National Specialised Services

This is a complex set of 41 groups of conditions managed nationally due to the rarity of condition or treatment facility. In addition NSD funds 35 sets of services at around 80 different NHS Trusts in England4. They are managed by the DoH in London and any Borders patients with conditions covered by these services are funded centrally by National Services Division of the CSA under a system of top slicing.

The National Commissioning Group (NCG) is responsible for commissioning nationally designated clinical services which are either very low volume or require rare skills. In some circumstances, the portfolio of NCG services overlaps with Scottish nationally-designated services, e.g. adult liver transplantation or ophthalmic oncology and pathology. Some services for very rare conditions are only available at national specialist centres in the UK or very occasionally abroad.

Requests for referral to these services may come from local clinicians or tertiary care centres. There is a need to ensure that the correct process is followed and that this is checked with NSD as referrals to services in England may need to be via a national centre in Scotland. The process should be to request approval with NSS in writing. Contact information and the list of services and providers can be found at

NSD makes a contribution towards the cost of Scottish residents accessing these services, although some are funded entirely by NCG on a UK basis. For more information on the NCG, please follow this link to the external National Commissioning Group website.

6. NHS Continuing Healthcare5

NHS Continuing Care is a package of continuing health care provided and solely funded by the NHS. NHS Borders, not Scottish Borders Council (or any other local authority) or an individual, pays the total cost of that care. NHS Continuing care may be for prolonged periods but not necessarily for life and entitlement should be subject to regular review. The care will be provided in a hospital ward, hospice or a contracted inpatient bed, which may be based in a care home. Any individual of any age with any illness or disability may be entitled to NHS Continuing health care. Eligibility is decided on assessed needs and not on the diagnosis of any particular illness. CEL 6 (2008) provides eligibility criteria for NHS continuing care in paragraph 44 and this is re-produced in Appendix 4.

7. Jointly Funded Packages Of Care

Jointly funded packages of care are when an agreement is made between NHS Borders and Scottish Borders Council to jointly fund the care that an individual person requires. Pragmatically this has often been on the basis of the split in costs being 50:50 of the net cost. The net cost total excludes any free personal care contribution; assessed client element or any other benefits. The packages of care are when a person does not qualify for NHS Continuing Health Care but the NHS accepts some responsibility to contribute to that person’s health needs usually for people under 65 years old. The care may be provided over an extended period of time to meet the physical and mental health needs of people which have arisen as a result of disability, accident or illness.

8. NHS patients receiving Healthcare Services through Private Healthcare arrangements6

A letter from the Chief Medical Officer (CMO(2009)3; 25 March 2009) provides guidance and a framework to support decisions concerning the possible combination of NHS and private care for individual patients. This includes medicines which are not available in the NHS or through the NHS Borders Guidance for Processing Requests to Prescribe Unlicensed, Off-label or Exceptional Treatments (medicines awaiting consideration by, or not recommended for use by, the Scottish Medicines Consortium)7

NHS Borders policy on NHS care following private treatment has been formulated to guide future decisions. This paper includes 6 principles to help in the decision making process and to assist clinicians who may be faced with requests from patients for treatment and care.

The situation covered by this guidance is different to the NHS funding treatment or care within the private sector through these ECR procedures – in this situation the NHS has accepted responsibility for fully funding the treatment and usually because it is not available locally of through existing SLAs. In the case of agreed jointly funded packages of care (see paragraph 1.7 above) both the NHS and local authority have accepted responsibility for funding, and there may be a financial contribution from the patient following routine local authority financial assessment procedures.

SECTION 2 – ETHICAL FRAMEWORK

This section details the ethical framework governing the decision making process to be adopted by NHS Borders. The process outlined in Section 3 of this paper is founded on a set of core principles to ensure that a transparent and reasonable ethical framework governs the decision making process about funding decisions for the categories of treatment/care outlined in Section 1.

2.1 Individual need and benefits from treatment

• All decisions will be taken on an individual patient basis and their prognosis should be considered.

• The default position will be that treatment is not offered unless and until all other options under existing agreements and contracts have been explored by the referring clinician.

• Evidence that a treatment or service confers a benefit to the patient and is the most appropriate treatment at this time should be considered. Effectiveness of the treatment/service should be considered against a variety of sources including national guidance (such as SIGN or if not available NICE guidance), other sources of clinical evidence (such as from the Cochrane Centre) and NHS Health Scotland as appropriate.

• Where the request for funding is being made for drug therapy, existing recommendations by SIGN and the Scottish Medicines Consortium must be taken into account. Reference should be made to NHS Borders Guidance for Processing Requests to Prescribe Unlicensed, Off-label or Exceptional Treatments (medicines awaiting consideration by, or not recommended for use by, the Scottish Medicines Consortium) 20097.

2.2 Equity/justice

• NHS Borders will aim to provide equal access to treatments/services for their residents based on patient need.

• NHS Borders has a statutory duty to achieve financial balance and decisions to limit access to treatments/services legitimately include aspects of financial cost. Decisions to treat inevitably divert resources from other health care options.

• Both cost effectiveness and the individual cost of treatment will be considered in NHS Borders decisions about which treatments to limit and in reaching decisions on individual patient needs.

• In some cases, the needs of a community for a range of treatments may outweigh the needs of an individual for a highly expensive treatment.

• Where an alternative, more cost effective solution can be found, it is appropriate for NHS Borders to consider alternative options.

2.3 Patient choice / autonomy

Patients and their clinicians have the right to request treatments/services and to have their case of need heard and considered. The criteria and process used for arriving at funding decisions must be transparent and equitable and the processes outlined in this protocol are intended to achieve this end.

SECTION 3 – REFERRALS PROCESS AND FUNDING APPLICATION PROCEDURE

NHS Borders expects all GPs and consultants to refer patients to local services or services commissioned by NHS Borders from other NHS areas in the first instance. In situations where it appears that no suitable service is available through either of these channels the GP/Consultant should contact NHS Borders, via the Senior Manager - Secondary and Community Contracted Services (referred to henceforth as the “Commissioning Manager”), in writing in advance of the referral to seek authorisation for the ECR. The process is outlined in the flowchart in Appendix 1.

Where a social worker, clinician or patient or their relative are wanting to request that NHS Borders jointly fund a package of care the relevant social worker should contact NHS Borders, via the Commissioning Manager, in writing in advance of the referral to seek authorisation for joint funding. Separate arrangements for agreeing joint funding of care for people with learning disabilities have been in operation for some time – these are taken forward through the joint LD service complex care panel. There is also a dedicated budget for admissions to the regional Managed Care Network beds or to units outside the NHS. Only those admissions which cannot be managed within these arrangements and the identified budget will be referred to the ECR process described below

Where a clinician is wanting advice on how to arrange specialised treatment funded by NSD they should seek advice from the Commissioning Manager at NHS Borders.

A. Within working hours

3.1 Funding requests for an ECR or jointly funded package of care treatment/service as outlined in Section 1 will need to be made by the referring clinician prior to the patient receiving treatment.

3.2 A request for funding should be accompanied by the following information:

• The patient’s medical history, including the prognosis of the patient;

• An outline of the proposed treatment/service including an indication of the likely duration of the treatment;

• Other options for treatment/service that have been considered by the referring clinician and the reasons for exclusion of all alternatives considered;

• Evidence of the clinical and cost effectiveness of the treatment/service (such as from SIGN or NICE guidance) and other sources of clinical evidence (such as from the Cochrane Centre) should be given wherever possible;

A funding application form is available on request and on the NHS Borders Intranet and must be used in all cases (see Appendix 2).

3.3 On receipt of the application form, the ECR Administrator will log the ECR requestonto the database.

3.4 The Commissioning Manager will review the request initially to see if it is appropriate to

NHS Borders, as follows:

• The patient is a Borders resident. They may be registered with a non-Borders GP - the key fact is that they live in the Scottish Borders.

• The requested service/procedure is not currently provided under an existing NHS contract or local NHS provider (if so, write to the referrer to refer the patient to the local/NHS service).

• The service/procedure is not the responsibility of NSD

• If a request is made to fund treatment outside of the UK, E112 and Article 56 guidance should be applied9.

• All requests will be anonymised by the ECR Administrator using the CHI number or other unique identifier before any information is passed to the Panel.

3.5 Where the patient is under the age of 18 years, the process for Children and Young People outlined later in this section should be followed.

3.6 The Commissioning Team will collate all information in preparation for consideration by the NHS Borders ECR Panel, including:

• The full costs of the treatment/service for which funding approval is being sought;

• The proposed provider of the treatment/service and evidence of the quality of service provided;

• Where appropriate, whether NSD has already been approached for funding.

3.7 Funding requests received by NHS Borders will be considered by the ECR Panel. The panel will meet weekly if required and will comprise at least three of the following (one of whom must be a clinician):

❖ Clinical Chairs of BGH, Primary & Community Services and Mental Health or deputies

❖ Director of Nursing and Midwifery or Deputy

❖ Director of Pharmacy or Deputy

❖ Commissioning Manager or Deputy

In addition relevant clinical representatives or local authority officers may be invited to attend if it is required to aid decision making. A Finance Officer may also attend to provide advice and support where necessary.

3.8 The NHS Borders ECR Panel will review all the information supplied on the agreed application form and collated by the ECR Administrator and will consider the appropriateness of the request based on the information supplied. The Panel will consider each case on its individual merit and will base their decision on consideration of the facts presented to them in line with the agreed core principles outlined in Section 2.

3.9 In reaching its decision on each individual case, the NHS Borders ECR Panel will consider:

• Whether the treatment is available through local services or existing commissioning arrangements?

• Whether the treatment has been recommended by a local clinician, or one working in a locally commissioned service, as the best option for the patient?

• Whether the treatment has an evidence base demonstrating efficacy ?

• Whether the quality assurance processes and outcomes of the organisation who will undertake treatment has been reviewed by NHS Borders ?

Evidence of efficacy may be available from SIGN or NICE guidance; other authoritative sources of evidence such as Cochrane reviews; or by seeking views and advice from relevant professionals within and outside NHS Borders. If a review of quality assurance systems has not been undertaken previously information should be requested from the organisation prior to final approval and this should be included in the letter to the referring clinician as a condition of approval. The Commissioning Manager should request relevant information from the organisation concerned and put it to the next meeting of the ECR Panel and the outcome should be recorded on the Panel Decision Record Form (Appendix 3).

3.10 When requested to consider funding of an aesthetic or plastic surgery treatment the Exceptional Aesthetic Referral Protocol within CEL 30 (2009) “Exclusion of Exceptional Aesthetic Procedures from the 18 week Referral to Treatment Standard and Existing Waiting Times Milestones” should be followed.10

3.11 Where a citizen of another EU country requests treatment within the NHS the guidance on Reciprocal Health Agreements should be referred to9. A series of Health Rights Information Scotland factsheets may also be of help for EU and other overseas visitors and are available at .uk.

(Original 3.12 re drugs requests removed)

3.12 The ECR Panel decision should be recorded on the Panel Decision Form (see Appendix 3). The form should be signed by a Clinical Chair present at the Panel meeting and include any necessary information such as:

• Treating organisation

• Full costs

• Any conditions of the referral

• Reporting / monitoring requirements

• Any proposals for future care or discharge arrangements

3.13 The decision of the ECR Panel will be conveyed by letter to the referring clinician (and GP if not the referring clinician), with the Commissioning Manager ensuring that this letter is sent to the clinician within 5 working days of the Panel reaching its decision. This letter should include:

• Decision reached and reasons for that decision;

• Any limit on funding agreed;

• Any conditions of approval of the funding request;

• Any proposals for future care/discharge arrangements;

• Any reporting/monitoring information required as a condition of the approval of funding;

3.14 The ECR Administrator will record the decision of the Panel on the Database:

3.15 Where there are likely implications for continuing health care either immediately or in the future the case should be discussed with the Director of Nursing & Midwifery.

3.16 Where a GP will be required to prescribe, the GP should be informed of the decision to fund and requested to arrange suitable shared care arrangements with the service provider.

3.17 The request, supporting evidence and completed Application Form should be recorded and filed in a Safe Haven. Anonymised data giving approval should be sent to the Finance Department for processing. Copies will be forwarded on to the Safe Haven Office for payment processing purposes including the allocation of a unique approval reference number.

3.18 Where an urgent request is received during normal working hours, the advice of the appropriate Clinical Chair or Medical Director should be sought. The advice of the Director of Nursing & Midwifery or DPH may also be sought as appropriate. Where there are likely to be implications for continuing health care either immediately or in the future, the funding request must be discussed with the Director of Nursing & Midwifery, Lead Nurse in the relevant Clinical Board or Head of Midwifery. When funding is approved because of the urgency of a particular case this should be reported to the next meeting of the ECR Panel.

B. Process for Emergency Referrals

3.19 The ECR panel makes decisions in relation to treatment requests not currently commissioned by NHS Borders. The panel meets weekly to decide whether or not to approve formal funding requests. It is inappropriate to refer emergency requests through the ECR process as this would be likely to compromise the patient’s treatment. All emergency treatments therefore need to take place without prior authorisation from the ECR panel and presented retrospectively to the panel as soon as possible for final approval. The panel reserves the right to make recommendations to change providers if more appropriate and cost effective care can be contracted.

3.20 In the event of a placement being necessary outside of working hours the following action should be taken:

• If it is on the margins of the defined times a call should be placed to the NHS Borders to be sure no one is available to deal with the issue.

• Should the requirement be for an inpatient bed the responsible clinical team, in liaison with the on-call Manager where appropriate, should ensure no bed locally can be released by reviewing the current occupancy.

• Should this not be possible all efforts should be made to identify an NHS bed within another appropriate service, firstly within Borders and then the rest of Scotland.

• Only if all reasonable efforts to secure an NHS bed have been exhausted should appropriate independent sector providers be considered. Due attention should be given to value for money issues.

• If a cost is to be incurred in securing a placement, following all necessary action being taken, this should only be agreed after approval by the on-call Director (available through BGH switchboard) and only for the minimum period possible (i.e. until the morning of the next available NHS Borders working day)

• On the morning of the next available NHS Borders working day, the person responsible for the placement should ensure NHS Borders is informed of the placement, the action taken and provide a recommendation for immediate management of the patient for the consideration of NHS Borders under the usual ECR processes.

• Providing all appropriate actions have been demonstrated NHS Borders will honour the funding commitment for the period outside of working hours.

C. Additional process to be followed for all requests for funding involving children and young people and adults at risk

3.21 This process needs to be read in conjunction with the Scottish Government Guidance[i] on establishing the responsible Commissioner. This applies to all children and young people up to the age of 18 years.

3.22 For all applications made to NHS Borders for funding:

• If the request has been supported following the ECR protocol as outlined above, the application will be approved with the condition that evidence of compliance with the essential safeguards as outlined in the Working Together to Safeguard Children (2006)10 and Scottish Borders Child Protection Guidelines[ii] is a requirement of funding and must be received and approved before placement. This should be included in the letter to the referring clinician and the Commissioning Manager should request evidence of compliance in a similar manner to that outlined above for the quality assurance systems.

• The Commissioning Manager will forward a copy of the best practice guidance document and the link to the Child Protection Procedures to the proposed placement/current placement with a covering letter.

• Evidence provided should be recorded and further evidence of compliance requested if needed.

• Approval for funding to NHS Borders finance department will only occur after receipt of the above evidence and approval at the following ECR Panel meeting and will be recorded on the Panel Decision Record Form (see Appendix 3)

• Update information on placements used on a regular basis by NHS Borders should be requested annually.

▪ Outside working hours the on-call Manager should liaise with relevant clinicians to assess compliance with essential safeguards and follow up with written evidence on the next working day.

3.23 The Adult Support and Protection (Scotland) Act 2007 provides ways in which support and protection can be offered to adults at risk of harm who are unable to safeguard themselves because they are affected by disability, mental disorder, illness or physical or mental infirmity. Where the patient is considered to be an adult at risk a copy of the organisation's Adult Protection Procedures must be requested along with evidence of implementation and monitoring. As for the arrangements outlined above for children this evidence should be presented to the next Panel meeting for approval and the same process should be followed outside working hours if admission is required urgently.

3.24 Where the patient is an identified adult at risk known to the Adult Protection Unit copies of the Risk Assessment and Care Plan should be requested and considered with the ECR application.

3.25 NSD is currently working with Regional Planning and NHS Board colleagues to implement the National Delivery Plan for Specialist Children’s services. The changes at a national level involve the development of new national specialist children’s managed clinical networks. These are for:

• paediatric cystic fibrosis

• paediatric rheumatology

• paediatric endocrinology

• children with complex health needs

• children’s cancer – to develop into a Managed Service Network

SECTION 4 – APPEALS PROCESS

4.1 Should the referring clinician or patient be unhappy with the decision taken by NHS Borders ECR Panel, they have the right to challenge the decision within 28 days of the letter being received by the clinician. Should a third party, other than the referrer, wish to appeal against the decision on behalf of the patient, written confirmation and authority must be gained from the patient by the third party, stating that they are acting on the patient’s behalf.

4.2 The referring clinician or patient/third party representative should write to the Chief Executive, clearly detailing the reason/s for their dissatisfaction. The letter can also provide additional/supporting information available, should it support the patient’s case of appeal.

4.3 On receipt of this correspondence, the Chief Executive will then identify a Director of the Board (not one involved in the original Panel decision) to review the case to ensure that NHS Borders process has been fully implemented and followed. Should all NHS Borders Directors have been involved in the original Panel decision the Chief Executive will identify an independent officer to review the case.

4.4 The review of the case must be completed within 28 days of the receipt by NHS Borders of the request for review of the case. Should it be anticipated that the review will require longer than 28 days, NHS Borders must inform the referring clinician/patient giving an indication of the amount of time that will be required to complete the review.

4.5 On completion of the review of the case, the outcome will be forwarded to the referring clinician/patient/third party representative within 5 working days of the review being complete.

4.6 Should the referring clinician/patient/third party representative remain dissatisfied following the review of their case, they will then be directed to NHS Borders complaints procedure. It would be good practice to include details of how to complain with the response to the review.

SECTION 5 – MONITORING ARRANGEMENTS

5.1 NHS Borders Commissioning Team will monitor applications received and their outcome on an on-going basis and will provide a summary report to NHS Borders Board on a six monthly basis.

5.2 This protocol will be reviewed on an annual basis by NHS Borders Commissioning Team and any changes approved by NHS Borders Board.

5.3 For all cases of NHS continuing healthcare provided outside NHS Borders monitoring arrangements, frequency and information requirements should be identified at the time of approval.

5.4 In the case of jointly funded packages of care monitoring arrangements should also be detailed in a service level agreement between NHS Borders, the provider(s) of care and the joint funding partner(s).

APPENDICES

Appendix 1 – Flowchart of ECR Procedure

Appendix 2 - Funding Application Form

Appendix 3 – NHS Borders Panel Decision Record Form

Appendix 4 - Eligibility for NHS Continuing Healthcare

Appendix 1 – Flowchart of ECR Procedure

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KEY TO RESPONSIBILITY:

Extra Contractual Referrals – Funding Application Form

What is an ECR?

ECR requests are for individual patients requiring treatment or care not provided locally by NHS Borders. All elective treatments to other Boards and English Trusts must be approved through the ECR process before referral, with the exception of some specialised services from Lothian, Newcastle and Carlisle. If you are in any doubt about our contracting arrangements, please contact us on 01896 820711.

You can fax, email or post the completed form:

Fax: Safehaven fax number 01896 823396

Email: Emailing from another borders.scot.nhs.uk account to jeanette.tuddenham@borders.scot.nhs.uk or lynn.bellis@borders.scot.nhs.uk is also a safe method of transmission

Post: Marked ‘Private & Confidential’ for the attention of the Commissioning Manager, 4 Nurses’ Flats, Dingleton Road, Melrose TD6 9QN

Queries: Telephone 01896 820711

CHI Number: ____________________ Patient Initials ____________________

Name of Referrer: _________________________ Designation: _____________________

Service/GP Practice: _______________________ Tel Contact: _____________________

|Questions |Comments/Brief Explanation |

|1. What is the treatment, procedure or appointment patient is | |

|being referred for? | |

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|2. Is this a one-off treatment, or will ongoing |Please circle: |

|appointments/care or treatment be needed? If ongoing care, | |

|please give an indication of the expected duration of care |One-off Ongoing |

|(weeks/months) | |

| |Duration: |

|3. What are your reasons for referring this patient? Please | |

|include a short medical background, or provide a supporting | |

|letter with full details. | |

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|4. What is the clinical evidence to support the use of this | |

|treatment? (Please include reference source of evidence based | |

|research – if available, e.g SIGN/NICE) | |

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|5. Please indicate any treatments the patient has already | |

|had/other options for treatment which may have been considered.| |

|If discounted, please explain why. | |

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For ECR Administration use only – see overleaf

For ECR Administration use only

| |Comments/Brief Explanation (must complete) |

|Approximate Cost of Treatment | |

|Date of NHS Borders ECR panel | |

|Decision on Funding Request |Approved / Denied |

|Level of Funding Approved | |

|File Number | |

|Pre-Contract Checklist if Independent Sector |Status: |

| |Approved In Progress Not Approved |

|For children only and adults at risk – have NHS Borders patients | |

|been treated by this provider before? Has there been a local | |

|assessment of their child & adults at risk protection arrangements?| |

|Contact point in provider for child & adult protection | |

|arrangements? | |

APPENDIX 3 - NHS Borders Panel Decision Record Form

|Date of Panel Meeting: |Panel Members Present: |

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|File Number: | | |

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|Patient Name: ……………………………………… Date of Birth: ……………………… |

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|Organisation who will undertake treatment/care: …………………………………… |

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|Brief details of referral request: |

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|Panel Decision (delete as appropriate): APPROVED / DENIED * |

|Level of funding approved: | |

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|Reason for decision reached and details of any conditions of funding, etc: |

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|Reporting/monitoring requirements: |

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|Proposals for future care or discharge arrangements (if any): |

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|Assessment of treating organisation’s quality systems: |

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|Assessment of child protection safeguards: |

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|Assessment of adult protection safeguards: |

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|I authorise/do not authorise the above ECR request and funding level as outlined above. |

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|Signature of authorising Clinical Chair………………………………………………….. |

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|Date……………………….. |

APPENDIX 4 – Eligibility for NHS Continuing Healthcare

Paragraph 44 of CEL 6 (2008) – NHS Continuing Healthcare

“44. Continuing inpatient care should be provided where there is a need for ongoing and regular specialist clinical supervision of the patient as a result of –

(a) the complexity, nature or intensity of the patient’s health needs, being the patient’s medical, nursing and other clinical needs overall;

(b) the need for frequent, not easily predictable, clinical interventions;

(c) the need for routine use of specialist health care equipment or treatments which require the supervision of specialist NHS staff; or

(d) a rapidly degenerating or unstable condition requiring specialist medical or nursing supervision.”

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References

1. NHS HDL (2004) 15 NHS Scotland: Guidance on establishing the responsible Commissioner.

2. MEL (1999) 4 – Funding arrangements for cross-boundary and cross-border patient activity.

3. HDL (2002) 39 Funding arrangements for Specialised Services and other Pan-regional Hospital Services.

4. NSD commissioned specialist services - see

5. CEL 6(2008) NHS Continuing Healthcare

6. SGHD/CMO (2009) 3 Arrangements for NHS patients receiving healthcare services through private healthcare arrangements.

7. NHS Borders Guidance for Processing Requests to Prescribe Unlicensed, Off-label or Exceptional Treatments (medicines awaiting consideration by, or not recommended for use by, the Scottish Medicines Consortium)

8. NHS Care Following Private Treatment, Dr Alan Mordue October 2010

9. Reciprocal Health Agreements: see ; CEL (30) 2010: Crossborder Healthcare and Patient Mobility: Advice on handling requests from patients for treatment in countries of the European Economic Area

10. CEL (30) 2009 Exclusion of Exceptional Aesthetic Procedures from the 18 Week Referral to Treatment Standard and Existing Waiting Times Milestones.

11. Working Together to Safeguard Children (2006)

12. Scottish Borders Child Protection Guidelines – see

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Referrer sends completed Funding Application Form

Not Borders patient, (send to relevant Health Board, copy to referring clinician)

NHS Borders via ECR Administrator

All ECR requests must be vetted by the Commissioning Team before processing

Incomplete Request (requires additional information e.g. cost/history) 28 day rule for completion before closure

Request logged onto ECR database – same day request received

Public Health Admin

Referrer

ECR Panel

Public Health Admin with advice from Commissioning

Completed Referral

CLOCK STARTS: 10 DAYS TO PRESENT AT PANEL(

Completed Form to be filed – Finance Dept notified

ECR Database to be updated with Decision

Decision conveyed to referring clinician

(In writing within 5 working days)

Funding Request Approved

Funding Request Denied

Funding Authorisation Form (ECRMON1) Completed

Must be signed by Clinical Chair

Borders ECR Panel

CLOCK STARTS: 5 DAYS TO RELAY DECISION (

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