Referral Management & Prior Approval Policy & Procedure For Services Outside of Hywel Dda University Health Board

Referral Management & Prior Approval Policy & Procedure For Services Outside of Hywel Dda University Health Board Policy Number: 019 Supercedes: Previous versions Standards For Healthcare Services No/s Version No: 3 4 Date Of Review: September 2014 October 2015 Reviewer Name: Completed Action: Approved by: Date Approved: Karen Thomas Update contact details IGC October 2013 update contact details Karen Thomas and minor updates BP&PAC 23/02/2016 New Review Date: October 2016 October 2016 Brief Summary of Document: The aim of this document is to ensure that the Referral Management and Prior Approval Procedure is clear to understand, and ensures that referrals are directed to the most appropriate NHS provider in a timely manner. To be read in conjunction with: The All Wales Individual Patient Funding Request (IPFR) Policy Welsh Health Specialised Services Committee (WHSSC) Referral Management Policy Classification: Corporate Category: Procedure Freedom Of Information Status Open Authorised by: Kathryn Davies Job Title Executive Director of Commissioning/Therapies & Health Science Signature A signed copy of this document is stored with corporate services

Database No: 019 Page 2 of 20 Version 4

Responsible Officer/Author: Contact Details: Dr June Picton, Karen Thomas Mary Owens Dept Tel No Medical Directorate 01437 834483 01437 834486 Job Title: Base E-mail: Associate Medical Director IPFR/RMC Manager Assistant Head of Financial Planning Withybush Hospital Haverfordwest june.picton@wales.nhs.uk karen.thomas20@wales.nhs.uk Scope ORGANISATION WIDE DIRECTORATE DEPARTMENT ONLY COUNTY ONLY Staff Group Administrative/ Estates Medical & Dental Nursing Allied Health Professionals Ancillary Maintenance Scientific & Professional Other Please indicate the name of the individual(s)/group(s) or committee(s) involved in the consultation process and state date agreement obtained. CONSULTATION Individual(s) Date(s) Group(s) Clinical Governance Committee Date(s) Committee(s) IGSC Date(s) 27/11/2015 RATIFYING AUTHORITY (in accordance with the Schedule of Delegation) NAME OF COMMITTEE BP&PAC A = Approval Required FR = Final Ratification A KEY Date Approval Obtained COMMENTS/ POINTS TO NOTE Date Equality Impact Assessment Undertaken August 2013 the review of the policy comprised updates on contact details and minor amendments which would not impact on staff or service users or other key stakeholders from any protected group/groups affected by the policy Group completing Equality impact assessment Commissioning Group supported by: Jackie Hooper, Equality & Diversity Advisor Please enter any keywords to be used in the policy search system to enable staff to locate this policy Database No: 019 Page 3 of 20 Version 4

Document Implementation Plan How Will This Policy Be Implemented? Through the normal policy implementation channels Who Should Use The Document? What (if any) Training/Financial Implications are Associated with this document? What are the Action Plan/Timescales for implementing this policy? All staff involved in the referral process N/A Action By Whom By When Policy to be approved at Clinical Policy Review Group (CPRG) Approved Policy to be signed by Exec Lead Signed Policy to be made active on intranet Active Policy to be advertised via global email to all staff Policy Co-ordinator Policy Co-ordinator Policy Co-ordinator Policy Co-ordinator Database No: 019 Page 4 of 20 Version 4

CONTENTS Page No 1 Introduction 5 2 Why Implement a Referral Management Centre? 5 3 The Scope of the RMC 3.1 New Referrals 3.2 Repatriation of Patients Receiving Long Term Care with External Providers 4 The RMC Team 7 5 The Role of the RMC 7 5-7 6 What Happens when the Referral is Received 7-8 7 The Clinical Need of Each Patient will be Considered Against the Following Criteria 8 When Making a Referral Decision the Following Needs to be Considered and Discussed with the Patient 8.1 Transfer Back to the NHS when a Patient has Self Funded in the Private Sector 8.2 Continuity of Care Patients Moving into Hywel Dda 8.3 Continuity of Care Outpatient Follow Ups 8.4 Continuity of Care Re-Referral Following a Previous Tertiary Referral 8.5 Treatment/Surgery Outside of Hywel Dda for Social Reasons 9 10-11 9 Funding Decisions 11 10 Recording Meetings 11 11 What Happens Following the Prior Approval Panel 12 12 Performance Management 12 13 Commissioning Decisions Appeals Process 12 13 14 What Happens Following the Commissioning Appeals Panel 14.1 Health Board Complaints Process 14.2 Confidentiality and Information Security 14.3 Process Review Appendices: 1. Flowchart for Decision Making 2. Prior Approval Application Form 3. Prior Approval Panel Terms of Reference 4. Commissioning Appeals Panel Terms of Reference 5. Commissioning Appeals Panel Process 13 14-23 Database No: 019 Page 5 of 20 Version 4

1. INTRODUCTION Hywel Dda University Health Board (HB) is responsible for providing all healthcare services to the citizens of the 3 counties of Carmarthenshire, Ceredigion and Pembrokeshire irrespective of where the patient is seen. The rural nature of the area presents its own unique challenges, however wherever possible, the HB will aim to deliver healthcare services as close as possible to the patient s own home when appropriate within the Hywel Dda locality and ensure that all Hywel Dda residents are receiving an equitable service. Consequently, only when all treatment options available within locally provided services have been exhausted and it is clinically appropriate, should patients access healthcare services elsewhere. Healthcare services provided outside of Hywel Dda are accessed by patients via clinical professionals through the following routes: The HB has Prior Approval (PA) agreements in place with NHS providers in Wales where there is an established pathway for referrals. In the main these arrangements are in place to provide planned tertiary care for sub specialities not available locally. PA for Non Commissioned Activity (NCA) Services that are not available locally or covered under existing PA arrangements. Referrals to healthcare providers outside of Wales where the patients require specialist care. Please refer to the Welsh Health Specialised Services Committee (WHSSC) Referral Management New Outpatient Referrals Guidance for Healthcare Professionals. 2. WHY IMPLEMENT A REFERRAL MANAGEMENT CENTRE (RMC)? The Referral Management Centre (RMC) is not a new concept to the HB. It is the bringing together the skills and knowledge of HB clinicians and managers under Individual Patient Funding Requests (IPFR) and PA with the aim of ensuring that systems are put into place that: Are consistent with Hywel Dda s clinical services strategy; Are clinically sound; Are efficient; Are making the best use of available resources; Ensure that all Hywel Dda residents are treated equitably. 3. THE SCOPE OF THE RMC 3.1. New Referrals Referrals into Hywel Dda UHB by HB Primary and Community Care clinicians do not form part of the RMC and should continue to be submitted to the HB in the usual way. In order to be as comprehensive as possible it is proposed that the RMC will cover as part of its core function: All GP and secondary care referrals outside Wales; All GP referrals; All GP and secondary care referrals excluding Hywel Dda but within Wales with the exception of Abertawe Bro Morgannwg University Health Board (ABMU) and Cardiff & Vale University Health Board (C&V) where different criteria apply; All GP and secondary care referrals to ABMU in the following specialties: Orthopaedics; Rheumatology; Dermatology; ENT; Paediatrics; Database No: 019 Page 6 of 20 Version 4

Gynaecology; Medicine, including Cardiology; Elderly Medicine; General Surgery; Ophthalmology; Pain Management; Community Hospitals; Open Access MRI or MRI when the service is not linked to another chargeable episode of care. All GP and secondary care referrals to C&V in the following specialties: Paediatrics; Clinical Immunology; Dermatology; Medicine; Rehabilitation; Rheumatology; Pain Management; ENT; General Surgery; Ophthalmology; Urology. 3.2. Repatriation of Patients Receiving Long Term Care with External Providers As well as the management of new referrals the RMC will undertake reviews of patients receiving longer term follow up appointments out of area. The intended outcome of this review would be to repatriate such patients to local services or discharged back to their GP when clinically appropriate to do so. Repatriation of patients will be assessed utilising the following clinical information: The last two clinic letters; Evidence that the continuation of care is based on clinical need (social needs cannot be taken into consideration); To be satisfied that there is no locally provided service available to meet the clinical needs of the patient. When a request for continuation of treatment out of area is received into the RMC the Referral Management Team (RMT) would scrutinise the referral, request further information if necessary and seek the opinion of an appropriate NHS consultant as to whether the requested service is available locally before consideration by the Panel. Only when the agreed criterion is met would approval be given for a patient to continue with out of area treatment. In some cases, if a patient has concerns regarding repatriation, the Panel would suggest that consideration be given to treatment on a shared care basis for the first 12 months. 4. THE RMC TEAM The clinical need of the patients and the sustainability of local services will be the focus of the decision making process of the RMC and the RMT will consist of: Database No: 019 Page 7 of 20 Version 4

Clinical Lead for IPFR and RMC (Associate Medical Director); IPFR and RMC Manager (Senior Nurse); Assistant Head of Financial Planning; Administrative and analytical support x 2; The expertise provided by clinicians making the referrals when required The expertise provided by the IPFR Panel of the HB when required 5. THE ROLE OF THE RMC The role of the RMC is to scrutinise all requests for out of area referrals that are received against the approved screening criteria within 2-4 days of receipt. Urgent referrals are reviewed on day of receipt. In order to avoid all cases having to go to an approval panel the RMC will operate a screening process based on the clinical need of the individual (social circumstances will not be taken into consideration) and the availability of services in the following order: 1. Within Hywel Dda; 2. Within Wales; 3. Outside of Wales. Please see Appendix 1 for a flowchart of this process. All referrals outside of Hywel Dda University HB will be processed by the RMT; thus preventing delays in patients being added to waiting lists. It is anticipated that this process will ensure that patients are being referred to the most appropriate provider, avoid duplication of correspondence and ensure that all Hywel Dda residents are receiving an equitable service. 6. WHAT HAPPENS WHEN THE REFERRAL IS RECEIVED? Patient referral forms will be accepted from: GPs with a supporting letter from an appropriate NHS Consultant/Specialist Consultants/Specialists working within NHS Hospitals and NHS Community Trusts or other NHS providers; Specialist Practitioners with a supporting letter from an appropriate Consultant. When a patient referral form (Appendix 2) has been received by the RMC the form will be logged, given a unique reference number and added to the database. The referrals will be scrutinised by the RMT against the referral criteria set out below and the agreed action will be taken by the RMT. Incomplete/illegible patient referral forms will be returned to the referrer with a request for further information. If all the necessary information has been included within the funding request and the referral meets the agreed criteria, the referral will be authorised and forwarded to the provider. In the case of a referral being rejected the referring Clinician, GP, provider and patient will be notified by letter. A flowchart detailing the process when a referral is received by the RMC can be found at Appendix 1. Database No: 019 Page 8 of 20 Version 4

7. THE CLINICAL NEED OF EACH PATIENT WILL BE CONSIDERED AGAINST THE FOLLOWING CRITERIA: Criteria Action Validation 1. Is the service/procedure requested available within Hywel Dda? 2. Is the service required covered under an existing Long Term Agreement (LTA), initially in Wales and then secondly an existing LTA in England? 3. Is the patient transferring back to the NHS from privately provided healthcare? (*see additional notes point 8.1 below) If Yes the patient referral will be redirected to the most appropriate consultant/department within Hywel Dda UHB. If No see Criteria 2 If the service is not available within Hywel Dda but is covered under an existing LTA within Wales the referral will be directed to the most appropriate Welsh provider. Similarly if the service is not available within Wales but is covered under an existing LTA within England the referral will be directed to the most appropriate English provider. Letter will be sent to referring clinician and the patient with advice regarding where to direct referral. A spreadsheet documenting the proposed action to be taken for each patient referral processed on that day will be scrutinised by the RMT and the action ratified by the Chair of the Prior Approval Panel. Some cases will not meet the specified criteria. These cases will be presented by the IPFR/RMC Manager to the PA Panel for consideration. If an urgent decision is required the application will be reviewed by an appropriate clinician on the day of receipt. The PA Panel will meet every 2 weeks to consider requests, this will be dependent on the exigencies of Panel members, having due regard to the duties detailed in the Terms of Reference (Appendix 3). The Panel will consider each case based on the supporting documentation supplied by the patient s referring clinician and other evidence presented to the Panel. Requests for treatment made directly by an individual or a third party (eg Assembly Member, Member of Parliament) will not be accepted. If a direct request is received, the patient will be advised to contact their GP or Consultant. Referrals will not be accepted from private providers Database No: 019 Page 9 of 20 Version 4

8. WHEN MAKING A REFERRAL THE FOLLOWING NEEDS TO BE CONSIDERED AND DISCUSSED WITH THE PATIENT: 8.1. Transfer back to the NHS when a Patient has Self Funded in the Private Sector If a patient has funded their own referral/treatment in the private sector, the HB cannot be expected to fund ongoing treatment which may include surgery or follow ups on the NHS. Consultants should not see patients privately and then expect to add them to NHS waiting lists. To ensure equity for all Hywel Dda residents, all such requests will be declined and the referring clinician and patient will be advised that they need to be referred to local services on the NHS. If a case is considered exceptional it may be referred to the IPFR team (see separate IPFR Policy). If however, a local service is not available for a proposed surgery/intervention and the Panel feels that it is clinically appropriate for the patient to be seen by a consultant on the NHS, funding may be approved. If funding is approved the RMT would expect the patient to be added to the NHS waiting list as is the case for all other Hywel Dda residents. The HB believes that to ensure equity for all HB residents, private providers have a moral obligation to ensure that the patient is in a position to fund an entire course of treatment before it is commenced. 8.2. Continuity of Care - Patients moving into Hywel Dda If patients move into Hywel Dda they will be expected to access services within Hywel Dda UHB. Some patients will request to remain with their existing care provider based on Continuity of Care. Hywel Dda UHB understands the importance of continuity of care; however we must endeavour to deliver as much as we can to patients locally. Where comparable services are provided locally or within Wales, we would expect patients to access those services. Consideration will only be given for a patient to remain with an existing provider if their specific clinical condition warrants Continuity of Care and it is deemed in the patient s best interest to remain with the existing service. Social needs will not be taken into consideration. Before the Panel could consider out of area funding on the basis of continuity of care, the RMC would expect a comprehensive report/letter from the existing consultant/specialist detailing specific clinical reasons why it would be in the patient s best interest to continue to be reviewed outside of Hywel Dda. 8.3. Continuity of Care Outpatient Follow Ups As a matter of routine if the RMC provides approval for treatment outside of Hywel Dda all approval letters will set out our assumptions regarding funding for 2 follow up outpatient appointments; following which the patient should be repatriated to local services. If however, there is a specific clinical reason for a patient to continue to be managed outside of Hywel Dda, the RMC would consider this but would require a completed PA form from the NHS provider with specific clinical evidence in support of continuation of longer term care in their organisation. 8.4. Continuity of Care Re-referral following a Previous Tertiary Referral for a New Episode of Care Patients frequently request to return to the same specialist centre for a new episode of care based on Continuity of Care. When services are available within Hywel Dda UHB, patients Database No: 019 Page 10 of 20 Version 4

will be expected to access those services. Hywel Dda UHB is unable to use specialist (tertiary) centres for core treatments/surgery that can be undertaken locally. 8.5. Treatment /Surgery outside of Hywel Dda for Social Reasons Patients occasionally request treatment/surgery outside of Hywel Dda in order to be near a relative/friend so that they can be cared for post operatively. Such requests will not normally be considered. The RMT will need to be satisfied that there are specific clinical reasons as to why it would be more appropriate for the intervention to be undertaken outside of Hywel Dda. In order for funding to be considered the panel would also need clarification around the proposed surgery, estimated recovery time and anticipated costs. Details would need to be provided around post operative care to include: Appropriate discharge planning information; GP and District Nurse cover; Family circumstances. 9. FUNDING DECISIONS The RMT will, in determining whether funding should be approved or declined, consider: Whether all local services have been explored; Whether all treatment options available within contracted services have been explored; The impact upon available resources; Funding applications for treatments or services undertaken without Prior Approval will not be considered (retrospective funding). Where it is deemed that further information is required, the RMT will assume that presumed consent has been given by the patient to access any medical notes/records pertinent to the request. The RMT may defer a decision pending receipt of additional information/evidence or clarification. 10. RECORDING MEETINGS Funding decisions made by the Panel will be clearly documented and will include the following information: The request/application form for each application; The factual background to the request for funding; The decision reached and a full account of the reasons behind the decision; Accurate minutes from each Panel. 11. WHAT HAPPENS FOLLOWING THE PRIOR APPROVAL PANEL? If approved, the referral will be to the provider within 3-5 working days with a copy being sent to the referrer. If funding has not been approved, a letter stating the reason(s) for the decision will be sent to the referrer within 3-5 working days with a copy being sent to the patient. Details of how to link to the Commissioning Decisions Appeals Policy is included within the policy (Appendix 4). 12. PERFORMANCE MANAGEMENT The HB will utilise the information from previous panel decisions as evidence that can be used to assist in future decision-making ie the PA/RMT will endeavour to look for trends etc. Database No: 019 Page 11 of 20 Version 4

The RMC will be subject to annual Key Performance Indicators (KPI) in order to set annual tasks over and above the RMC core function and to measure the effectiveness of the RMC. The annual tasks relating to referral management and the outcome and information expected to be achieved will be communicated to clinicians at the start of each financial year. 13. COMMISSIONING DECISIONS APPEALS PROCESS It is important that any decision making process has an integral mechanism for handling appeals. The function of the Commissioning Appeals Panel (CAP) is to consider whether the original PA process was carried out correctly and appropriately. It is important to note that it is not the remit of the CAP to reappraise the case or reconsider the decision made. It should be noted than an appeal cannot be made against a funding decision alone. An appeal is not an opportunity to reopen arguments and issues upon which the PA Panel has reached a formal recommendation and subsequent decision. The CAP will not substitute its own judgement for that of the PA Panel or look afresh at the evidence submitted to the PA Panel. If new evidence is submitted this will be reconsidered by the PA Panel outside of the appeals process. An appeal can only be made on the following grounds: An error of principle, such as a failure of the original panel to follow the principles set out in the Referral Management Procedure; An error of fact, such as a failure to understand the nature of the applicant s clinical need or the purpose for which the proposed treatment is sought to be funded. All appeals should be made in writing by the referring clinician directly to the Chief Executive of the Hywel Dda UHB. All appeals will need to be made within 25 working days from the date of dispatch of the letter detailing the decision. All letters must be specific in detailing the grounds for which the appeal is being made. An acknowledgment letter will be sent within 5 working days of receipt of the appeal, and the CAP will be informed. Any further information or clarification requested by the CAP should be provided by the referrer within 10 working days of the request. The CAP will endeavour to meet within 25 working days of receipt of the written appeal to review the case, taking into consideration the duties detailed in the Terms of Reference (Appendix 4). The CAP will consider the appeal in the context of evidence presented as per the All Wales IPFR Policy in line with the process detailed in Appendix 5. 14. WHAT HAPPENS FOLLOWING THE COMMISSIONING APPEALS PANEL? If an appeal is successful the case will be re-referred to the PA Panel with the reason(s) for the decision and the PA Panel will be asked to review the case taking into account the recommendations of the CAP. If an appeal is rejected the patient s advocate will be notified of the reason(s) for the decision. A decision letter is sent to the referrer, GP and/or consultant as appropriate. The decision letter will state whether or not the appeal has been upheld and the reason(s) for the decision will be given. Please see Commissioning Appeals Process (Appendices 4 and 5). Database No: 019 Page 12 of 20 Version 4

14.1. Health Board Complaints Process The complaints procedure is available to the patient/clinician. If they wish to follow that process they should be directed to the HB s complaints policy. 14.2. Confidentiality and Information Security In operating the Commissioning Appeals policy the HB will have due regard to the need to ensure that patient confidentiality is maintained at all times; all communication relevant to a patient s case will be anonymised to ensure patient confidentiality. The HB complies with the requirements of the Data Protection Act and Caldicott Principles of Good Practice. 14.3. Procedure Review This procedure will be reviewed at 24 month intervals. Database No: 019 Page 13 of 20 Version 4

APPENDIX 1 - FLOW CHART FOR DECISION MAKING Referral from GP, Consultant or Other Health Professional Referral from an English or Welsh Trust Referral date stamped, unique reference number allocated and assessed for completeness on same day by RMC Admin Referral Complete Referral incomplete Referral entered on RMC Database Log referral on spreadsheet for KPI analysis. Screen against RMC criteria within 2-4 working days of receipt Return to referrer requesting additional information Complex case forward to IPFR Manager to take to PA Panel Case does not meet criteria for referral Case meets criteria for referral IPFR Manager to review case for gate keeping, research treatment and service provision in and out of Wales RMT to redirect to appropriate local services RMC team screen and sign off referral with the IPFR Manager s approval. All decisions are ratified at the PA panel. Additional referral data entered on database RMC Database Additional referral data entered on database RMC Database Referral forwarded to service provider within 3-5 working days from receipt. Panel minutes produced from database IPFR/PA Panel meet (usually fortnightly). Referral forwarded to local service provider. Letter sent to inform referrer, GP, patient and provider, within 3-5 working days from panel date. Case approved Case not approved Case deferred Letter sent to inform referrer, GP and provider, within 3-5 working days of panel date. Letter sent to inform referrer, GP, patient and provider, within 3-5 working days of panel date. Letter sent to referrer, requesting clarification, within 3-5 working days of panel date. Database No: 019 Page 14 of 20 Version 4

APPENDIX 2 PRIOR APPROVAL APPLICATION FORM REFERRAL FORM (Prior Approval) Contract No: This form will constitute a referral and will be sent directly to the service provider if funding considered appropriate. Refer To: Name: Speciality: Address: GP Details: Name: Surgery: Address: Postcode: Telephone Number: Fax Number: Patient Details: Name: Address: Postcode: Smoking Status - No per day: (If considered necessary for referral) Postcode: Telephone Number: Fax Number: Date of Birth: Age: NHS Number: Clinical warning: (eg allergies, blood-borne viruses) Weight & BMI: (if considered necessary for referral) Telephone No: Alcohol Consumption Units per week: (If considered necessary for referral) Speciality: (Please note if Cancer then please refer to South Wales Cancer Network within Hywel Dda) Details of requested treatment and cost: Medical history: Does this patient have any long standing clinical relationships with the referral centre: Yes No If yes please state in what capacity: Database No: 019 Page 15 of 20 Version 4

Is this service available within Hywel Dda? (If the service is available within Hywel Dda (refer to list of services) the patient should be referred to local services in the first instance) Current Medication: (if applicable) Additional Information: (Letters/reports can be attached if required) Please note if patient transport is required it is the responsibility of the referring clinician to organise following approval. Referring GP/Consultant /or other Healthcare Professional (Please note if referrer is other than the GP/Consultant a letter of support from a GP/ Consultant is required) I confirm that as the patient s Consultant/GP, I have discussed this application with my patient and he/she is aware that the Referral Management Team may need to access further clinical information pertinent to this funding request and that this request is being made with his/her consent. Clinician s Signature: Name: Designation: Address: Telephone Number: Fax Number: Date: Please return completed forms to: Referral Management Centre Withybush Hospital Fishguard Road, Haverfordwest, Pembrokeshire, SA61 2PZ Telephone: 01437 834486 Safehaven Fax Number: 01437 772402 Database No: 019 Page 16 of 20 Version 4

APPENDIX 3 PRIOR APPROVAL PANEL TERMS OF REFERENCE Constitution: The Board hereby resolves to establish a panel to the Board to be known as the Prior Approval Panel. The panel has no executive powers other than those specifically delegated in these terms of reference. Membership: The panel shall comprise: IPFR Manager (Senior Nurse); Medical Director Representative; Finance Representative; Or their appropriate authorised deputies. Quorum: The panel will be quorate if 2 members are present (1 clinical). Attendance: The IPFR Administrator will support the panel. Frequency: The PA Panel will meet every 2 weeks to consider requests, this will be dependent on the exigencies of the service, having due regard to the duties detailed in the Terms of Reference. In the event of an urgent need to meet, the IPFR Manager can contact panel members to discuss the case. Authority: The panel is authorised by the Board to approve funding for commissioned and noncommissioned activity after having assessed and determined whether all treatment options available within local and contracted services have been explored. The Panel s Duties: To scrutinize individual patient requests for non commissioned treatment in terms of clinical and financial appropriateness taking into account: Details of requested treatment; The patient s medical history; Evidence that all local services have been explored; Current medication (if applicable). To decide whether to approve or decline requests for funding of prior approval referrals/treatments and to convey the decision to the referrers. Database No: 019 Page 17 of 20 Version 4

To agree on specific conditions for funding, and where applicable, to ensure that decisions are reviewed on a regular basis. To maintain a library of evidence that can be used to influence future decision-making ie looking for trends etc. Reporting and Recording of Decisions A summary report of all requests and decisions by the Referral Management/Prior Approval Team will be provided to the Clinical Effectiveness and Audit Committee (CEAC) meeting on a 3 monthly basis. Any issues that require executive action will be brought to the attention of the CEAC. Database No: 019 Page 18 of 20 Version 4

APPENDIX 4 - COMMISSIONING APPEALS PANEL (CAP) TERMS OF REFERENCE Constitution The Board hereby resolves to establish a panel of the Board to be known as the Commissioning Appeals Panel. The panel has no executive powers other than those specifically delegated in these terms of reference. Membership The panel shall comprise of: The HB Medical Director or Clinical Non Officer Member (Chair); Community Health Council Representative; Non Officer Member. The panel will be quorate providing 3 members are present. None of the members of the appeal panel will have had any prior involvement in the original submission. Attendance The IPFR Administrator will support the CAP. Frequency The CAP will endeavour to meet within one month of an appeal being received by the Chief Executive of the HB. Authority The panel is authorised by the Board to hear appeals on the process followed by the PA Panel and to uphold or reject appeals. Duties To hear appeals against the PA Panel process and determine whether or not to uphold these appeals; To inform the referrers of the outcome of their appeal; In the event of upholding an appeal, to refer the case back to the PA Panel and the reason for the CAP panel upholding the appeal. Reporting and Recording of Decisions A summary report of all requests and decisions by the CAP panel will be provided to the CEAC. Any issues that require executive action will be brought to the attention of the CEAC. Database No: 019 Page 19 of 20 Version 4

APPENDIX 5 - COMMISSIONING APPEALS PANEL (CAP) PROCESS Referring clinician writes letter of appeal to the Chief Executive, stating grounds for appeal, within 25 working days of receipt of Prior Approval decision letter HB acknowledges receipt of letter within 5 working days Request responded to and information received by CAP coordinator Request forwarded to IPFR/PA Administrator. Entered onto database IPFR/PA Administrator convenes CAP and sends out papers to Panel 5 working days prior to meeting. Database CAP meets to consider cases CAP considers case and further information or clarification on particular aspects of the appeal is requested CAP considers case and makes a decision IPFR/PA Administrator sends out CAP s request for information Appeal Upheld - notification to referrer and case referred back to PA Panel to be reconsidered Appeal not upheld - notification to referrer within 5 working days. Database No: 019 Page 20 of 20 Version 4