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Referral pathways

Annex B - Vetting panels, appeals process, monitoring arrangements

National Referral Protocol
National

In order to ensure that the National Referral Protocol guidance is being applied fairly and consistently across Scotland, NHS Boards are required to set up vetting panels to monitor adherence and to consider appeals.

It is for NHS Boards to agree whether vetting panels operate on a local, regional or national basis, however Boards are required to provide assurance that appropriate arrangements are in place to the Chief Medical Officer by 1 December 2025.

Composition of vetting panels

NHS Boards will agree the composition of their vetting panels, however the recommended minimum composition of vetting panels (to be established by NHS Boards either individually or collectively), follows:

  • A Clinical Psychologist (from one of the Regional Psychology Services)
  • Admin support
  • A Senior Nurse
  • Consultant x 2
  • A General Practitioner.

NHS Boards must ensure that all procedures covered this protocol are considered by a vetting panel. Where no local panel exists, they must ensure they have arrangements in place to access another panel.

Frequency

Minimum of one vetting panel meeting per month.

Appeals process

Where a vetting panel rejects an appeal case, the individual concerned has a right to appeal the decision of the original vetting panel through the following process:

  1. Level 1 – A full case review by the original local vetting panel considering any additional information provided by the patient/GP.
  2. Level 2* – Case sent to an independent panel for review.
  3. Level 3 – Formal Health Board complaints procedure.

* A level 2 review can only be triggered if the patient contests the outcome of the level 1 review.

Monitoring/review of protocol

The National Referral Protocol Working Group will continue to meet annually to look at the volume of NRP procedures being provided and feedback to vetting panels to ensure this guidance is being applied fairly and consistently across Scotland.

  • The first review will take place 12 months after the launch of this protocol.

NHS Board Vetting panels must collect the following data from each local team/ Unit and submit their data to the National Referral Protocol Working Group for consideration:

  • Number of referrals received.
  • Number of referrals initially removed by triage.
  • Number of referrals entering the vetting panel system
  • Number of referrals successful at the vetting panel
  • Number of referrals unsuccessful at the vetting panel
  • Number of level 1 appeals
  • Number of level 2 appeals
  • Number of complaints received.
  • Number of clinical psychology referrals.

Sample testing - 3 times a year a sample of cases will be vetted by another vetting panel. This will involve a random selection of 10 procedures being selected by each Unit and sent on rotation to another vetting panel for consideration.

NHS Boards are required to describe the arrangements they have in place as part of the assurance given to CMO by 1 December 2025.