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Prior Funding Approval Scheme

 

We supported South Sefton CCG and Southport & Formby CCG working with local providers to ensure clinically effective treatments were funded appropriately. With their new electronic Prior Approval Scheme, the CCGs have reported a fall in activity and expenditure of £412,000 (19%).

Background

The priority for CCGs is that funds are spent on treatments and procedures which bring the greatest value and benefits to patients in a way in which is affordable and equitable. The challenge was to change behaviour, educate clinicians, improve the patient journey, reduce inappropriate referrals and ensure consistent outcomes.

Action

Our streamlined solution involves educating clinicians and creating a bespoke system for submitting applications for funding. The Prior Approval Scheme involves the provider of treatment seeking funding approval from the commissioner prior to treatment. CCGs can challenge providers for activity that does not have the relevant authorisation codes generated by the scheme, ensuring only appropriate treatments are delivered.

We worked with South Sefton CCG and NHS Southport & Formby CCG to design an electronic system for clinicians to submit requests for treatment based on best practice and the outputs from their manual system. A useful feature is the facility to save a partially completed form and return later, if more information is required before submission.

The electronic Blueteq system is very straightforward, requiring minimal input from clinicians to submit applications for treatment and upload required evidence. The system can provide automated decisions where appropriate for specific procedures or can be flagged for further consideration by the Prior Approval team. An authorisation code is automatically generated once the request has been processed, allowing CCGs to challenge providers if codes are missing, which ensures only appropriate treatments are delivered.

With Chorley & South Ribble and Greater Preston CCG the initial focus was to build working relationships with commissioners and referring clinicians to ensure they were informed and that they understood the requirements of the scheme. One critical element was to ensure all applications received a decision within five working days to adhere to hospital waiting times and avoid any delays in patient care. Reporting mechanisms were developed and continually reviewed in line with CCG requirements.

Impact

With their new electronic Prior Approval Scheme, the CCGs have reported a fall in activity and expenditure of £412,000 (19%). Improved service pathways and implementation of a referral management service which worked alongside the Prior Approval Service also contributed.

We also worked with Chorley & South Ribble and Greater Preston CCG to develop and implement a robust manual Prior Approval Scheme for seven policies over an initial six-month period. In addition to the monitoring and validation of activity data, we captured qualitative data in relation to themes and trends affecting potential future commissioning intentions.

Inappropriate referrals at Chorley & South Ribble CCG and Greater Preston CCG have fallen, resulting in efficiency savings and improved patient flow. Health outcomes have improved by ensuring the right treatment for patients at the right time. Clinicians are managing patient expectations more appropriately, improving patient experience and reducing misunderstandings and complaints. Working relationships are enhanced between stakeholders, with a culture of continuous improvement. The scheme has been extended for two more years, and 15 procedures added.

Hospital providers involved so far have praised the system, saying they would like all CCGs to commission this process so there would be a single, robust and efficient system, making processing applications simple and easy for clinicians.

I’ve always found the IFR Team to be very approachable and highly professional.  They are consistent and efficient in the administration of the IFR process, appear very knowledgeable and are always willing to provide advice and assistance regardless of the nature of the enquiry.

The team clearly recognise the importance of listening to patients and clinicians. They are patient focussed and always endeavour to deliver a responsive, flexible, empathic and patient-led service.
Dr Matthew Orr, GP Director and IFR Panel Member, Chorley and South Ribble CCG