Evidence-based advice to inform commissioning decisions on “Interventions Not Normally Funded”

1. Evidence-based advice to inform commissioning decisions on “Interventions Not Normally Funded” Dr Arif Mahmood Specialist Registrar in Public Health National Public Health service for Wales Dr Mary Webb Health Service Quality and Development Team National Public Health service for Wales

2. Policy Context • The Welsh Health Circular (2003) 63 - LHBs and Health Commission Wales are the statutory commissioning bodies in Wales • And the NPHS has a responsibility to provide public health resources and expertise to enable them to carry out their statutory duties • “Designed for Life” and “Fulfilled Lives and Supportive Communities” - identified commissioning as a vital tool to reform health and social services • The WHC (2007) 023 – identified commissioning as a process to specify, secure and monitor services that are evidence-based, cost effective, of high quality and meet individual needs

3. NHS Core Values • Fairness • Effectiveness • Efficiency • Responsiveness • Integration • Accountability • Flexibility

4. Guiding principles for commissioners • Legality (is it lawful?) • Safety ('first do no harm') • Clinical Effectiveness (does it work?) • Cost Effectiveness (is it an efficient way of using resources?) • Equity (is it a fair way of using resources?) • Accessibility (can people get to the service?) • Affordability (do we have the resources to pay for it?)

5. Purpose of the INNF advice • The document is intended to promote: • Evidence based commissioning • Efficient use of finite resources • Equality across Wales

6. What is “INNF”? • Any intervention (medical, surgical or drug based treatment) which fulfils one or more of the following criteria: • There is currently insufficient evidence of clinical effectiveness • There is currently insufficient evidence of cost effectiveness • The intervention is considered to be of relatively low priority for NHS resources locally

7. What is exceptionality? • In order for funding to be agreed there must be some unusual or unique clinical factor about the patient that suggests that they are • Significantly different to the general population of patients with the condition in question • Likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition

8. Why we did it? (1) • In 2003, most LHBs adopted the commissioning policies of the old health authorities • The NPHS frequently gets requests from LHBs for evidence-based advice on Interventions Not Normally Funded (INNF) • In December 2006, Gwent LHBs decided to develop a joint commissioning policy and requested advice on INNF

9. Why we did it? (2) • Client’s (Gwent LHBs) needs • Health Service Quality and Development Team capacity • Would other LHBs be interested? • The NPHS decided to roll out its advice across Wales

10. How we did it? • An INNF list was compiled after consulting with LHBs across Wales • INNF Policies of a number English PCTs were also scrutinised • Evidence of clinical/cost effectiveness for each intervention was searched for • Market research – what sells?

11. Features of NPHS advice on INNF • 50 interventions • OPCS Codes • References • Hierarchy of evidence – Grading of recommendation • Quality Assurance • Advice review

12. Caveats • The primary responsibility for commissioning remains with the LHBs and HCW, and the NPHS has only an advisory role • Must not be interpreted as “Blanket Advice”, • Commissioners should deal with each request on its merit considering the individual circumstances of the patients and also adhering to the specified guidance • The commissioners will continue to be legally responsible for their decisions and consequences

13. Consultation • This documented has been consulted on with: • Local Public Health Directors • LHB Medical Directors • LHB Nursing Directors • LHB CEOs - South East Region • LHB CEOs - Mid & West Region

14. Next steps • Consultation with Health Commission Wales – 30th November 2007 • Consultation with the National Specialist Advisory Groups – 30th November 2007 • Final approval by the Health and Social Care Strategic Management Group of the NPHS – 18th December 2007 • Publication on the NPHS website – 31st December 2007

15. Format of the document Orthodontic treatments for essentially cosmetic nature (Code: F14.-, F15.-) Background:Orthodontic dentistry specialises in aligning crooked teeth. The treatment involves wearing braces. Quite often this treatment is undertaken for cosmetic reasons. Advice: Commissioners may only fund orthodontic treatments for essentially cosmetic nature in accordance with the guidance specified below (Evidence grade D). Guidance Orthodontic treatment is usually not offered to people with a score of less than 4 or 5 on the Index of Orthodontic Treatment Need (IOTN). • References • Brook P H and Shaw WC (1989). The Development of an Index of Orthodontic Treatment Priority. European Journal of Orthodontics II: 309-320. • Richmond S; Shaw W C; Stephens C D et al. Orthodontics in the General Dental Service of England and Wales: Critical assessment of standards. British Dental Journal 1993; 174: 315.

16. Acknowledgements • Dr Sarah Aitken • Dr Jenny Harries • Dr Michael Thomas • Dr Nina Williams • Ms Jo Charles • Dr Ash Paul (HCW) • Dr Richard Quirke • Ms Ruth Treharne (SE RCU) • LHB Nursing Directors Group • LHB CEOs – Mid & West Wales • Dr Nigel Monaghan • Dr Chris Potter • Mr Andrew Jones • Ms Sandra Caple • Mr John Frankish (NPT LHB) • Ms Jennie Willmott (Monmouth LHB) • Ms Angela Jones (Monmouth LHB) • Ms Isabel Puscus • LPHDs • LHB Medical Directors Group • LHB CEOs – SE Wales