Formulary appeals

Knowing that you need a formal appeals process for formulary decisions, it should not be a real issue if you think this through.

The starting point is the establishment of a robust process. By this I mean that you write down clearly how you are going to manage any formulary application and decision.

Here are my suggestions on a process:

Application – obviously any stakeholder can submit an application for a non-NICE recommended medicine to the formulary. The form must be clear and a supporting guide to support the applicant.

Triage and Initial Review – a member of the formulary group should triage the application. Is it appropriate for this committee and within our terms of reference are we able to make a decision? Obviously this refers to the decision map that I have mentioned before. The review is a process of discovery where the applying clinician works with the formulary committee and other stakeholders to refine the application and insert supporting data.

Committee Review – the completed application and supporting data is presented to a group of stakeholders who complete the decision matrix (also described in a previous blog) and the committee approves the decision.

Communication – the decision must be appropriately communicated in a clear and transparent way that allows clinicians, patients and other stakeholders to understand.

Review – at this stage the clinicians or for that matter any stakeholder are able to ask the committee to review their decision. Despite the committee’s best efforts it is possible that they have made a mistake, not considered all of the available evidence, not appreciated the patient angle or made incorrect interpretations. It happens and the committee can be asked to review their decision.

The appeal comes in when someone feels that the committee has not followed their published process and have therefore been derelict of their duties. The appeal should go, in the first instance, to a senior member of staff – perhaps the medical director or a non-exec director. The appellant must demonstrate that due process has not been followed. The director, should they agree that there are grounds for appeal – ie there are deficiencies in process – then they must construct an appeal panel to hear the evidence.

So the lesson here. Write down the process and keep to it. People may not always agree with your decisions, but as long as you follow the process, then there will be no grounds to appeal.

For support in developing superb process contact Richard in the MMP.


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