Individual Funding Requests
Making the best use of our limited resources and prioritising what we spend public money on are of crucial importance in providing the best possible NHS service across Surrey Downs.
To help us prioritise, we use national and local policies to ensure that the treatments and medicines we commission have a clinically proven benefit in meeting the health needs of the population.
This means that we won’t routinely fund individual treatments or medicines that do not have clinically proven benefit. For some procedures or medicines we fund subject to national and local criteria being met.
For procedures, see our “List of procedures that are not routinely funded requiring individual funding applications”, “List of procedures with restrictions and thresholds”, and “Assisted conception” Clinical Governance policies for further details.
For medicines, see the “List of specialised medicines”, which outlines the specialised medicines that may be funded and the circumstances in which they are funded.
What are procedures with restrictions and thresholds, and specialised medicines?
Alongside providing routine healthcare, the CCG also commissions highly specialised health services which require clinicians to consider unusual treatments which may meet the needs of their patients.
The CCG has reviewed evidence of clinical effectiveness, as well as information on current national activity and cost-effectiveness, and has put in place criteria for decision-makers with regard to those procedures within the “List of procedures with restrictions and thresholds” policy.
Specialised Medicines in our “List of Specialised Medicines” will be routinely funded where a request meets national and local criteria. In this instance, medicines will be marked “tick box” OR “invoice” in the right-hand column. If a tick box form is required, this will be completed by your consultant.
I don’t meet the criteria / the treatment I need is not listed. What can I do?
If you do not meet the criteria, you may still be eligible to receive funding for treatments if there’s evidence that your circumstances are either rare or clinically exceptional – in which case you may be eligible for “individual funding” and your clinician would be required to make an individual funding request.
Likewise, if the procedure you require is included within our “List of procedures that are not routinely funded requiring individual funding applications” policy your clinician would be required to make an individual funding request.
If the medicine that you require is not on our “List of specialised medicines”, it may be because the drug is funded by NHS England rather than the CCG. Your consultant will be able to advise in this instance.
How will IFRs be considered?
All IFRs are reviewed via a screening process to check for eligibility for consideration by the IFR Panel.
If you meet the criteria for a procedure within in the “List of procedures with restrictions and thresholds” policy, funding will be approved and the CCG will pay for your treatment or medicine.
If the requested treatment is listed within in the “List of Procedures that are not routinely funded requiring individual funding applications” policy or you do not meet the criteria for a procedure within the “List of procedures with restrictions and thresholds” policy, the IFR Panel members will consider whether your case is rare or clinically exceptional. They will also check that the procedure or
medicine you require is not routinely available, is not covered by an existing commissioning policy or CCG process, and would not amount to a service development.
The IFR Panel meets on a monthly basis and includes lay members and GP representation from each of the five Surrey CCGs.
IFRs can be considered by the IFR Panel on the grounds that either:
- The patient is suffering from a medical condition or clinical presentation which is considered rare and for which the CCG has no policy because the low probability of the condition occurring among the CCG’s population means that an explicit policy is not warranted (“A rarity request” which equates to 1 in 2.5 million); or
- The patient is suffering from a presenting medical condition for which the CCG has a policy but where the requested treatment has not been agreed to be funded under the policy (“An exceptionality request”) and the patient’s clinical circumstances are considered by the requesting clinician to be exceptional. When considering exceptionality, the CCG will consider whether the patients’ clinical circumstances are outside the range of clinical circumstances presented by at least 95% of patients with the same medical condition at the same stage of progression. The patients’ clinical circumstances must be shown to be sufficiently unusual that they could properly be described as being exceptional.
If the IFR Panel agrees there to be evidence that your case is “rare” or “clinically exceptional”, there is sufficient evidence that the proposed treatment is likely to be clinically effective, and it is considered to be a cost effective use of NHS Resources, the CCG will pay for your treatment or medicine.
The IFR Team will notify the requesting clinician of the Panel’s decision within ten working days of the meeting.
The IFR Panel may refuse a funding request, and this is always a difficult decision. In this case, the IFR Team will provide a detailed response to the requesting clinician (and the patient if requested) confirming the rationale for the decision to decline funding.
How can I challenge a decision made by the IFR Panel?
A patient or their clinician can write to the CCG to request a review of a funding decision made by the IFR Panel within one calendar month of the date of the outcome letter to the requesting clinician notifying them of the decision of the IFR Panel. A request to review an outcome can be made on the grounds that:
- There was procedural irregularity in the original decision making process; or
- There is evidence to suggest that the IFR Panel failed to consider and take into account relevant information, or apply appropriate weighting to that information when reaching its decision.
An appeal cannot be lodged against a decision made at the screening stage.