NHS Clinical Commissioning Groups are allocated a sum of money by NHS England to spend on patient care for their area. CCGs must decide what treatments and medicines should be provided for the population as a whole, trying to balance demand with the budget available. There are competing demands on the NHS budget and ways of treating patients are always changing. Sometimes there may be new medicines or operations developed, or there may be better ways of helping people that do not require medical intervention (for example weight loss might improve joint pain in some patients or giving up smoking might improve breathing).
Sometimes there are treatments which are considered to be not clinically effective enough for most people, or not cost effective enough, and are therefore not provided by the NHS. This is a decision taken by the CCG, after careful clinical scrutiny, and is often in keeping with CCGs in other areas. Often in such cases there might be alternative treatments available.
However, on an individual basis there may be situations where a doctor believes that their patient’s clinical situation is so different to other patients with the same condition that they should have a treatment paid for when other patients would not. In such cases, NHS clinicians can ask the CCG, on behalf of a patient, to fund such treatment and this request is called an Individual Funding Request (IFR).
A panel of experienced clinicians and managers meet to consider each IFR, to decide whether an application is ‘exceptional’ or not.
Funding for additional treatments outside the annual investment process can only be done by reducing the funding that is available for other established treatments. There is not an allocated separate budget to meet the costs of providing treatments agreed through the IFR process. It is because of this that very careful consideration is required before the decision is taken to fund a treatment for an individual that is not usually available.
When a new service or a change to a service is proposed, it would not be fair for that to bypass the annual investment process and be funded without comparing it to other possibilities for investment. Because of this, the CCGs default position is that a new service will not be routinely commissioned until it has been assessed through the full service development process.
Very occasionally a development is of such importance that there should be no delay in its introduction. If this is the case it will be considered as a matter of urgency by a CCG on an individual basis.
West Norfolk CCG Clinical Thresholds
To find all relevant Clinical Threshold Policies please follow the link below:
Who can make an Individual Funding Request?
If your GP or Consultant agrees a certain treatment would be of benefit to you and there are no alternative treatments or services available for your condition, they can make a request to the IFR Panel on your behalf but only if they consider your individual circumstances are exceptional.
As part of the IFR application, your GP or Consultant is asked to describe your personal clinical circumstances, how they believe the treatment will specifically benefit you, the evidence which is both safe and effective, the cost of the treatment and how commonly your condition occurs in the community.
All requests are treated in strict confidence and all personal details are removed from the paperwork before being submitted to the IFR Panel.
How is a decision made?
The IFR Panel is made up of health professionals and CCG managers who meet once a month to consider requests against an agreed set of criteria to ensure the decision making is fair, consistent and transparent. You will not be asked to attend the Panel meeting.
A letter will be sent to your GP or Consultant informing them of the Panel’s decision within 10 working days of the panel meeting explaining the reasons for the decision. Your GP or Consultant will contact you to discuss the decision so it can be fully explained. Your GP or Consultant can then discuss with you what it means for your care and the next steps which may need to be taken.
What can I do if the request is declined?
In the first instance you should speak to your GP or Consultant. If you, your GP or Consultant are unhappy with the IFR Panel decision:
In any case where further relevant information becomes available which has not been considered by the IFR Panel, your Doctor may ask the IFR Panel to reconsider the case specifically in light of this further information; and
Where all the relevant information was available to the IFR Panel when the decision was made, but the referring clinician remains dissatisfied with the decision, they may request it to be reviewed by the IFR Appeals Panel on one of the following grounds only:
Due process was not followed; or
The IFR Panel failed to give a clear rationale for its decision.
In the case of failure to follow due process or an inadequate rationale for the IFR Panel decision, your Doctor may request an IFR Appeals Panel review by making a formal request in writing to the Chair of the IFR Panel and copied to the IFR Administrator within 30 working days of the date of the IFR Panel’s decision.
The role of the IFR Appeals Panel is to determine whether the IFR Panel has followed its own procedures, has properly considered the evidence presented to it and has come to a reasonable decision upon the evidence. The IFR Appeals Panel shall not have power to authorise funding for the requested treatment but shall have the right to make recommendations to the IFR Panel.
Should you, your GP or Consultant remain dissatisfied with the IFR Appeals Panel decision, the matter may be pursued through the NHS Complaints Procedure. Information on how to do this is available from the relevant NHS Norfolk and Waveney CCG Complaints Manager.
All Individual Funding Requests may be reviewed by the CCG as the statutory body responsible for funding decisions. The application form and any other supporting information supplied may therefore be shared with the CCG or other trusted organisations legitimately acting on behalf of the CCG. Personal information may be retained only for the purposes of this Individual Funding Request and, in some cases, may be used for invoicing and payment reconciliation and your medical records may be used for the purposes of clinical audit which will be completed by a clinician. Anonymised information may also be shared as part of CCG reporting processes.
Your GP or Consultant will explain the funding process to you and will inform you of any funding decision made, including your right of appeal, if appropriate.