Procedures not routinely funded

Herts Valley CCG aim to provide excellent healthcare services for its residents, but as with other NHS organisations there is a limited budget, therefore we have to prioritise what procedures and treatments we fund.  There are some medical procedures that are either not routinely funded or require patient to meet an eligibility criteria before they can have the treatment/procedure. These procedures are referred to by HVCCG as ‘low priority/threshold procedures’ (LPTPs).  As a results the CCG have put in place Individual Funding Request and the referral and funding process for conditions that are low priority or require a clinical threshold to be met.

What is a low priority/threshold procedure (LPTP)?

Low priority/threshold procedures (LPTPs) are procedures considered to be of low clinical priority, such as surgery for cosmetic reasons. There is evidence that many of these treatments or procedures are clinically effective and could bring benefit at an individual level. However, the role of the CCG is to ensure that limited budget is directed to best meet the identified health needs of the population and therefore must take a view on population level prioritisation of relevant interventions and treatments. This approach is undertaken with the development of each new policy.

A full list of procedures and referral forms can be found here

Why does HVCCG have LTTP policies?

Many CCGs nationally, including HVCCG, have LPTP policies to:

• Provide clear guidelines for clinicians
• suport clinicians to access treatments for patients, to make sure that these treatments provide the greatest possible health gain to patients in the greatest need
• make the best use of NHS resources for patients

What is the prior approval process?

Herts Valleys CCG funds certain LTPTs through a Prior Approvals process. The Prior Approval process assesses patients against ‘threshold criteria’, a set of criteria that must be met in order for a patient to be eligible for treatment. 

A clinician must decide if a patient meets the threshold criteria set out in the CCG's Prior Approvals Process for each LTPT procedure.  If a patient does not meet the relevant criteria, the treatment will not be funded.

If a patient is assessed as not meeting the threshold criteria for a given procedure, their clinician may request the procedure through an Individual Funding Request (IFR).  Clinicians can make an application via an IFR process only when they believe that the patient has ‘exceptional’ clinical circumstances.

Individual Funding Requests (IFR)

Some procedures/treatments are needed very rarely as a result the CCG does not have a policy on them. Instead, the CCG decides whether to fund them on an individual basis. 

These procedures require Individual Funding Requests (IFRs) to be sent to the CCG's IFR Panel for assessment. The IFR Panel then decides whether the funding should be given.

What is exceptional case?

An exceptional case is when a patient is deemed to have exceptional clinical circumstances, i.e. a patient who has clinical circumstances which, taken as a whole, are outside the range of clinical circumstances presented by a patient within the normal population of patients with the same medical condition and at a similar stage of progression as the patient, exceptional to the cohort.

Out of Scope:

Patients with suspected or diagnosed cancer