Commissioning (Service restrictions) policy 

Criteria that define whether groups of patients are eligible for a treatment under specific circumstances. All providers must adhere to these criteria, and no individual prior approval request is required.  Compliance is assured through contractual monitoring, audit and performance assurance processes.

Criteria defining whether an individual patient is eligible for a treatment under specific circumstances. Ordinarily, these treatments require prior approval from the ICB on a patient by patient basis. However, where a provider is subject to contractual monitoring and assurance processes—such as audit, activity review or compliance reporting—the requirement for submitting individual prior approval requests may be replaced by those contractual mechanisms, provided the provider can demonstrate that all patients treated meet the criteria set out in the relevant commissioning policy.

Patients who received treatment under a commissioning policy previously in place within one of the predecessor ICBs (Mid and South Essex, Hertfordshire and West Essex, or Suffolk and North-East Essex) where the commissioning position or eligibility criteria have since changed. Where clinically required, any repeat, revision or replacement treatment will be assessed against the current Essex ICB commissioning policy, unless a time‑limited legacy arrangement remains in effect pending harmonisation.

May include requests for funding for patients with conditions for which the ICB does not have an agreed commissioning policy, including patients with rare conditions, and patients whose proposed treatment is outside agreed commissioning policies or service agreements. Such requests must demonstrate exceptional clinical circumstances to be successful.

Treatments which have been assessed as Low Clinical Priority by the ICB and therefore not funded unless there are exceptional clinical circumstances (exceptionality). 

Refers to a patient who has a clinical circumstance outside the range of the normal population of patients with the same medical condition and stage of progression or who may benefit more than other patients from the proposed treatment (see ‘Definitions’ Essex ICB Individual Funding Policy)

The Board retains overarching accountability for the commissioning decisions of the ICB, in particular those for restricting services.  The Board delegates responsibility (through the scheme of reservation and delegation (SORD)) for managing service restriction to the ICB Medical Director, who is able to approve (through the Executive Team) certain changes without recourse to the Board.

The Board, however, reserves authority to approve changes in service restriction where they are considered (one or more of) significant, complex, controversial and cross-cutting and have a financial impact congruent with the levels set out within the SORD.

The Audit, Risk and Compliance Committee is the sponsoring committee for this policy on the basis that it sets out the governance process to be followed for commissioning decisions. It is not the responsibility of the Audit Committee to make decisions on any given service restriction, but just to ensure that there is appropriate governance over how those decisions are made.

Restriction to services or any change to commissioning decisions must be grounded in clinical expertise.  Sponsoring committees include groups formed of clinical experts in a given specialty.  This may include stewardship groups.

The role of the sponsoring committee/stewardship group is to ensure that any suggested change to commissioning policy or service restriction is presented/considered by clinical experts in their field who understand the implications of the change and rationale for change that may have resulted from research and clinical guidance (e.g. from the National Institute for Clinical Excellence, NICE).

The Equality & Diversity Impact Assessment Panel is responsible for review and approval of impact assessments and consequently oversight of the impact of EDI work within the ICB, including the impact of changes to commissioning decisions / service restriction.

 The ICB Executive Team is responsible for receiving recommendations from the Executive Medical Director and approving changes to commissioning policy and the restriction of services where they are considered a ‘minor’ change.  This means the change is based on clinical guidance, is supported by appropriate clinical experts and does not have a significant impact on services or financial resources.

The Chief Executive is accountable for changes in commissioning decisions that are approved other than by the Board and is responsible for ensuring adequate processes exist to govern decision making.

The Executive Medical Director is responsible for ensuring that this policy has been followed when presenting commissioning/service restriction decisions to the Executive Team, and Board.

All proposed changes to commissioning policy/service restriction policies must be assessed by the Public Health representative as part of the Equality and Diversity Impact Assessment Panel.

The Public Health representative will also provide invaluable expertise in relation to health needs, demography and decision making.

All proposed changes to commissioning policy/service restriction must be assessed by the Director of Pharmacy, Medicines and Clinical Policies as part of the Equality and Diversity Impact Assessment process.

The Director of Pharmacy, Medicines and Clinical Policies will also provide invaluable expertise in relation to interpretation of NICE guidance in decision making.

The Director of Pharmacy, Medicines and Clinical Policies is also responsible for establishing arrangements for decision making for medicines and medicines related devices, which will be in line with the Medicines and Medicines Related Devices Commissioning policy but outside the arrangements detailed in this policy. (see appendix B).

The Director of Pharmacy, Medicines and Clinical Policies is responsible for updating this policy as required.

Line managers must ensure that staff are aware of and follow this policy.

All staff must be conversant with this policy and ensure that it is implemented and taken account of in their daily operations or interactions with Providers.

The ICB Decision Making Policy must be followed when making commissioning / service restriction decisions.  Thresholds set out within the SORD apply to all decisions and therefore approval routes set out within the Decision-Making Policy and SORD must be followed.  However, there may be circumstances where the Board reserve the power to approve a decision because of its complexity or impact, regardless of the level of resources required.

In principle, all proposals for changes to commissioning policy/service restriction policies must be presented from a sponsoring clinical committee/group and be assessed by the Equality and Diversity Impact Assessment Panel in the first instance. 

Where proposed changes are minor and have either a neutral or budgeted impact less than the defined level of authority within the Scheme of Reservation and Delegation for an Executive Director, this will be presented to the Executive Team for approval, by the Executive Medical Director. 

Complex, controversial or cross-cutting (e.g. impact on system partners) will be reviewed by the relevant programme clinical group/committee before progressing through ICB decision making.

Significant changes and those requiring financial contribution will require a business case to be completed, as per the Decision-Making Policy, and then according to their complexity and financial value will be presented to the Commissioning, Quality and Resources Committee, Executive Committee and Board (refer to SORD for thresholds).

Other Committees may be consulted where appropriate and as defined within the Decision-Making Policy.

Formal public consultation and consultation or engagement with Partners or Stakeholders may also be necessary in certain circumstances as defined within the Decision-Making Policy.

Commissioning Policy/Service Restrictions will be set out within a specific policy statement following approval. A list of the clinical policy statements is included in Appendix B and will be updated periodically to ensure that this policy is up to date.

Commissioning/Service Restriction policy statements will be published on the ICB website to ensure transparency and public accountability.

The Equality and Diversity Impact Assessment Panel are responsible for implementing a commissioning policy review cycle and will track service restriction policies to ensure that they are reviewed in line with their published review date, which should not exceed 5 years, or earlier if national guidance and policy become available to require a policy statement review.

All commissioning must be underpinned by population health outcomes methodology and based on value for money, defined as securing the best mix of quality and clinical effectiveness for the resources available. 

The Essex Integrated Care Board (ICB) commissions only those treatments and interventions that form part of an established, explicitly commissioned care pathway (as set out in service specifications and contract schedules) or that have been identified for funding through the commissioning process. Treatments outside these arrangements are not routinely funded.

Providers must not assume that the absence of a commissioning position for a treatment/procedure—whether in this policy, in an associated Service Restriction Policy, or within commissioned pathways and service specifications—implies that it will be funded. Only treatments that are explicitly commissioned, meet the relevant criteria, and comply with either prior approval or contractual assurance requirements will be funded. Where contractual monitoring, audit or compliance reporting arrangements are in place, these may replace the need to submit prior approval requests, but providers must still evidence full compliance with the criteria.

Patients are expected to be managed in a clinically appropriate setting that delivers the required care at the lowest appropriate tariff, where this does not compromise quality or outcomes. Where a procedure can be delivered in a lower cost setting (e.g., outpatient instead of day case), that setting should be used.

Where audit or activity review demonstrates that a procedure could have been delivered in a lower cost setting, the commissioner will reimburse only at the lowest appropriate tariff.

Commissioning policy development is an ongoing process. Updates arising from NICE guidance, health technology assessments, new evidence or other national or local developments will be produced and published periodically on the ICB website.

For certain commissioned procedures, the ICB operates a Prior Approvals Scheme, which sets out clinical and eligibility criteria based on evidence and relative priority for funding. These criteria apply to both Group Prior Approvals and Individual Prior Approvals. Criteria for procedures are set out in Appendix B, and criteria for prescribing are available via the ICB Medicines SharePoint site. 

This document sets out the access criteria for treatments that fall under the Prior Approvals Scheme and the circumstances under which these criteria must be applied.

Providers are contractually obliged to comply with the Prior Approvals Scheme and to ensure that only patients meeting the relevant criteria are treated. Failure to comply constitutes a contractual breach, and activity that does not meet criteria or approval requirements will not be funded.

Group Prior Approvals (previously known as threshold approval) are those treatments which are commissioned by the ICB on a restricted basis only for patients who meet the defined criteria set out within the relevant commissioning policy but for which individual prior approval is not required e.g. hip or knee replacement.

For these treatments the criteria listed apply to both the referring and treating clinicians.

Primary care clinicians e.g. GPs should not refer patients who do not meet criteria which they can assess.  This not only takes up an unnecessary outpatient appointment but results in a poor patient experience.

Equally treating clinicians should review referrals and return to the referring clinician those where it is clear from the information provided that the patient does not meet criteria, thus reducing the number of inappropriate outpatient appointments. 

ICB notification of compliance or audit will be required according to contractual arrangements.  Providers should be aware that payment may be withheld where they cannot demonstrate that patients treated meet the criteria specified.

Group Prior Approval must reflect the commissioning policy in force at the time the patient is clinically assessed as requiring treatment and listed for that procedure. The application of Group Prior Approval criteria is valid for 12 months from that point. Where waiting times exceed 12 months, or where a patient reaches the top of the waiting list after the 12‑month period has expired, the patient must be reassessed against the policy then in force and compliance with the criteria re‑evidenced before treatment proceeds. Providers must not delay applying or evidencing Group Prior Approval criteria until the patient approaches their treatment date.

This process and associated time limits will apply unless an alternative policy is subsequently introduced for a named procedure.

Individual Prior Approvals (IPA) are those treatments that are commissioned by the ICB only for patients who meet the defined criteria set out within the relevant commissioning (Service Restriction) policy and for which explicit authorisation from the ICB is required on a patient‑by‑patient and treatment‑by‑treatment basis where relevant.

Where IPA is required, approval must be obtained before the treatment is undertaken, and the approval must be clearly linked to the procedure to demonstrate authorisation. Any activity undertaken without the required approval, or without evidence that the criteria have been met, will not be funded.

In some circumstances, the ICB may agree that robust contractual monitoring, audit or compliance‑reporting arrangements replace the need for providers to submit individual approval requests. In all cases—whether formal approval or contractual assurance—the same eligibility criteria apply, and providers must be able to evidence full compliance before treatment is provided.

For eligible prior approval treatments, the criteria apply to both referring and treating clinicians. Where IPA is required, referring clinicians (e.g. GPs) must obtain approval before referral or booking an outpatient appointment. Where contractual assurance requirements apply, clinicians must ensure patients meet the criteria and providers must maintain evidence of compliance. 

Individual Prior Approval – or equivalent evidence of compliance under contractual assurance—must reflect the policy in force at the time the patient is clinically assessed as requiring treatment and listed for that procedure. Approval (or assurance) is valid for 12 months from that point. Where waiting times exceed 12 months, or where a patient reaches the top of the waiting list after the 12‑month validity has expired, the patient must be reassessed against the policy then in force and a new Individual Prior Approval request must be made, or compliance re‑evidenced under contractual assurance, before treatment can proceed. Providers must not delay seeking approval or evidencing criteria compliance until the patient approaches their operative date.

These processes and associated time limits apply unless superseded by a subsequent commissioning policy for the specific treatment.

Where the ICB is the responsible commissioner, treatments may be designated as ‘not funded’ where there is insufficient clinical evidence to support routine commissioning, where evidence exists but the treatment is considered a low priority for funding within available resources, or where the treatment does not meet established commissioning criteria. In these circumstances the treatment will not be funded except in cases of genuine clinical exceptionality. Applications for individual patients may be submitted through the Individual Funding Request (IFR) process but should only be made where the patient demonstrates true clinical exceptionality.

Following the establishment of Essex ICB, it is recognised that different commissioning policies and funding criteria operated across the former Mid and South Essex, Hertfordshire and West Essex, and Suffolk and North-East Essex ICBs. Some patients will therefore have received treatment under a legacy commissioning position that is no longer in effect or whose criteria have subsequently changed. Where, for clinical reasons, a previously funded treatment requires repetition, revision or replacement, the current Essex ICB commissioning policy and criteria will apply.

Where a patient was listed for treatment under a legacy ICB policy and had met the eligibility criteria in force at the time of listing, the Essex ICB will honour that commissioning position for a transition period, provided the treatment can be completed within 12 months of the original listing date. If treatment cannot be undertaken within 12 months, or the patient reaches the point of treatment after this validity period has expired, the patient must be reassessed against the current Essex ICB commissioning policy and criteria before the procedure can proceed. This ensures that legacy patients are treated fairly while maintaining consistency with Essex ICB’s harmonised commissioning approach.

In certain service areas, immediate harmonisation of commissioning policies across the three predecessor ICBs has not been possible due to the requirement for wider system engagement or, where there is potential for material service change, formal public consultation. In such circumstances, the relevant legacy commissioning position will continue to apply until a harmonised Essex ICB policy is developed and approved through the appropriate governance, engagement and consultation processes. The ICB will maintain oversight of these arrangements to ensure they are applied consistently and equitably during the transition to a unified commissioning framework.

The ICB allows clinicians to make funding requests through the Individual Funding Request (IFR) process where a patient has a condition for which there is no applicable commissioning policy, or where the proposed treatment falls outside the criteria of an existing policy or service agreement. Such requests may include patients with rare conditions or those for whom the treating specialist considers there to be clinically exceptional circumstances.

IFRs should be submitted only by the clinician responsible for providing or overseeing the proposed treatment; GPs should not normally submit IFRs, as requests should follow completion of the appropriate commissioned pathway and specialist assessment.

IFR requests must not be used to seek funding for service developments where more than one patient would reasonably be expected to benefit.

Exceptional clinical circumstances (exceptionality) refer to a patient who has clinical circumstances which are outside the range of clinical circumstances presented by a patient within the typical population of patients with the same medical condition and at the same stage of progression as the patient. There are two tests to apply to exceptionality:

• Are there any clinical features of the patient’s case which make the patient significantly different to the general population of patients with the condition in question at the same stage of progression of the condition?
• Would the patient be likely to gain significantly more clinical benefit from the requested intervention than might be normally expected for the general population of patients with the condition at the same stage of the progression of the condition? 

The ICB Individual Funding Request Policy defines the process for managing IFRs and should be followed at all times.

The Equality Act 2010 protects individuals from unfair treatment on the grounds of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex and sexual orientation. The Act requires providers to make reasonable adjustments for patients with disabilities, including (but not limited to) providing interpreters, carers, accessible communication formats, and other forms of support necessary to enable equitable access to services.

Providers must ensure that all commissioned services are delivered in an inclusive and non‑discriminatory manner and that reasonable adjustments are embedded within routine service delivery, rather than treated as an additional or exceptional cost. These adjustments form part of providers’ statutory responsibilities and are expected to be absorbed within existing commissioned service models.

Accordingly, applications for additional ICB funding solely to meet providers’ Equality Act responsibilities are unlikely to be supported. Commissioning decisions will continue to be guided by the requirement that services are accessible, inclusive, and compliant with equality and health inequalities duties as set out in the Equality Act 2010 and the ICB’s Equality and Health Inequalities Impact Assessment processes.

The Children and Families Act 2014 places statutory duties on local authorities and partners in relation to children and young people with special educational needs and disabilities (SEND). Under this legislation, young people with an Education, Health and Care Plan (EHCP) may continue to receive support up to the age of 25, where this is required to help them achieve their educational and developmental outcomes.

Commissioned services delivering care for children and young people must therefore ensure that appropriate provision is available for those aged 19–25 who hold an EHCP, reflecting their assessed needs and outcomes. Providers must discharge their responsibilities in line with the SEND Code of Practice and ensure that services remain accessible, inclusive and compliant with statutory duties.

Reasonable adjustments or additional support required under SEND legislation and the EHCP process form part of providers’ statutory obligations and are expected to be delivered within the commissioned service model. In the absence of a relevant funding policy for statutory SEND duties, requests for additional ICB funding are unlikely to be supported.

A C2C referral may be made without returning the patient to their GP where one or more of the following criteria apply:

• Cancer or suspected cancer, including referrals that fall within two-week-wait pathways. 

• Urgent or life-threatening clinical need, where the patient must be assessed within four weeks or sooner, and it would be unsafe or inappropriate to route via primary care. 

• Adult or child safeguarding concerns requiring immediate onward specialty involvement. 

• The patient is under 19 years of age, where direct onward referral is clinically appropriate. 

Same-condition onward management, where the required specialty input is directly related to the presenting condition for which the patient was originally referred or admitted. In these cases, the onward referral forms part of the same episode of care.

A C2C referral must not be used:

• For incidental or unrelated findings that do not require urgent clinical intervention. In these cases, the consultant must inform the GP of the findings through the clinic or discharge letter and must not recommend that the GP re-refer the patient into acute services, in order to preserve the patient’s legal right to choice. 

• Where a commissioned community or triage pathway (e.g., CAS, MSK, dermatology triage) exists and is the appropriate next step.  Such referrals should be directed to the community pathway rather than another hospital specialty. 

For unrelated conditions requiring non-urgent specialist input, patients should be returned to their GP so that referral can be made in line with patient choice legislation and the standard commissioned pathway. 

For all permitted C2C referrals:

• The referral must be clearly recorded in the clinical notes as a Consultant-to-Consultant referral, including the reason and the permitted category. 

• The patient must be informed of the onward referral and the reason for it, either at the time or as soon as feasible afterwards. 

• The patient’s GP must be notified in the clinic or discharge letter and provided with sufficient information about the decision and clinical background. 

C2C referrals should be made only by a consultant or equivalent senior clinician (out of hours: the most senior doctor responsible for the patient).

This section interacts with elective access rules but does not replace provider Elective Access (Referral to Treatment) policy. Providers remain responsible for applying national Referral to Treatment rules in line with the National Elective Access Policy (2025).

Where an unrelated elective tertiary referral is required and primary care cannot refer directly, the consultant should complete the referral and advise the GP. This is considered separate from same-provider C2C activity. 

Providers must ensure that all C2C referrals are coded correctly and auditable using the relevant referral source codes (e.g., “referral from consultant” or equivalent). Providers will provide assurance to the ICB that C2C activity complies with the criteria above, appropriate use of commissioned community pathways, and preservation of patient choice.

C2C referrals must not be used to bypass commissioning policies or to gain access to treatments requiring Prior Approval or IFR consideration. Where a procedure or intervention falls under an existing commissioning policy, the clinician must follow that policy and the relevant PA/IFR processes. This ensures equitable access and alignment with commissioning intent, in line with Section 6 of this policy.

• Ensure clinical documentation clearly records the procedure or treatment and identifies the relevant Service Restriction Policy (SRP) under which the activity is being delivered. Where the SRP requires Individual Prior Approval, an approval request must be submitted to the IFR Team unless the provider is operating under an agreed contractual assurance arrangement.

• All required supporting documentation (e.g., clinical notes, diagnostic test results, eligibility assessments) must be attached to the approval request or retained within the provider’s assurance records, as applicable.

• Where contractual assurance applies, providers must record the internal assurance ID or coding used, along with the evidence confirming that the patient met the required criteria, for audit and contract‑monitoring purposes.

• For any procedure requiring Individual Prior Approval under the relevant Service Restriction Policy, authorisation requests will normally be processed within three (3) business days, provided that all required clinical information is submitted. 

• Prior approval will be determined using the information provided in the application. Where the evidence required to determine the application is incomplete or absent, the request will be declined. Applicants must submit a new application with all required information before prior approval can be reconsidered.

• The ICB Individual Funding Team will periodically undertake audit and review of adherence to prior approval, contractual assurance, coding and authorisation standards. This includes verifying that approval IDs or contractual assurance identifiers are recorded appropriately, that criteria have been correctly applied, and that providers are complying with the agreed commissioning and assurance processes.

The Provider Billing & Coding Team must:

• Assign diagnostic and procedural codes based on clinical documentation, ensuring alignment with national coding standards and the ICB’s commissioning policies, including all relevant Service Restriction Policy (SRP) and Evidence-Based Interventions (EBI) coding requirements set out in Appendix C, or any subsequent updated standards.

• Record all required authorisation identifiers, including Individual Prior Approval (IPA) numbers and contractual-assurance identifiers, where the provider is operating under an agreed contractual-assurance arrangement.

• Ensure coding is complete, accurate, and auditable, evidencing compliance with commissioning criteria and supporting contract monitoring, activity validation, and payment processes.

The aim of this policy is to set out the governance, principles and processes underpinning the commissioning of services, including the application of Service Restriction Policies (SRPs), Prior Approvals and contractual assurance. The intended outcome for staff is to ensure a consistent, transparent and equitable approach to commissioning decisions, enabling staff to understand their responsibilities, apply commissioning criteria appropriately, and operate within a clear framework aligned to Essex ICB governance requirements.

This policy relates to commissioning governance and decision‑making processes, rather than the delivery of services or access pathways themselves. It does not introduce or amend clinical criteria for treatment; instead, it provides a framework for how such decisions are governed, documented and approved. As such, no differential impact on protected groups has been identified.

Equality and Health Inequalities Impact Assessments (EHIIAs) are completed at the point individual SRPs or commissioning decisions are developed or revised, ensuring that any potential impact on protected groups is assessed at the appropriate stage.

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Every 2 years as a minimum and earlier if there are any significant changes in legislation, policy or good practice.

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