There are a number of elective care treatments/interventions that are not routinely funded or commissioned by NHS CCGs. Applications for these treatments are considered through the IFR process.
- A NHS doctor, or other NHS health care professional directly involved in the care of a patient, can make a request for funding to support a healthcare intervention which has not been funded by the CCG under their approved policies.
- The application must be made by a clinician providing NHS services and the funding request should be in support of treatment by that clinician or an onward referral by that clinician. However, GPs are expected to apply for funding if it’s clear that a referral to secondary care is for a specific treatment covered by priority policies (for example, a referral for Varicose Veins surgery).
- The clinician requesting funding must ensure the funding form is completed as accurately and comprehensively as possible and submitted with supporting clinical evidence. This will ensure there are no delays in considering the treatment request. The requesting clinician will be best placed to know the patient’s clinical condition, the pathway of care for that condition and the options for treatment. They will also be familiar with the incidence and prevalence of the condition and have an understanding of their patient’s needs in relation to others whose clinical circumstances are broadly similar.
- South, Central and West CPIS Team will provide guidance to the referring clinician related to the progress of an application.
- The referring clinician should act as the patient’s representative and responses to funding requests will be made direct to the referrer.
- Where a request is declined, the CCGs recognise their obligations under the NHS Constitution to explain decisions to the patient but maintain the importance of the referring clinician’s role in explaining clinical issues and rationale.
It is the responsibility of the requesting clinician to set out the case for funding and to provide all relevant supporting information; the requesting clinician can also include supporting information provided by the patient. A fully-completed application will normally include:
- an outline of the patient’s diagnosis/problem and the clinical circumstances of the case, including any previous treatment(s) used and outcomes achieved;
- a clear statement of the referral/treatment plan proposed for the patient, to include the point at which the patient should return to local treatment pathways (or including the expected duration of the proposed treatment);
- consideration of reason(s) why the patient’s needs cannot be met within existing pathways;
- a statement of the reason(s) why this treatment, which would not be offered to others with similar clinical need, is a priority for funding in the individual patient’s case, i.e. what are the exceptional clinical circumstances?;
- a statement of evidence of clinical and cost-effectiveness if this is a new treatment not yet funded;
- the anticipated cost of the treatment (and associated costs) if it is outside the NHS tariff;
- the expected healthcare benefits (e.g. impact of likely outcomes on the Activities of Daily Living) if the requested treatment is provided, set against expected outcomes if the patient remains within the service or continues with treatment provided within existing CCG contracts.
If a patient, who has been treated privately, wishes to transfer their treatment onto the NHS their GP/healthcare professional should refer them onto the local NHS pathway for treatment. For further information please look under the relevant general CCG’s policy page.
There are two main kinds of funding request:
1. Procedures of Limited Clinical Value (Low Priority) treatments
PLCV are treatments/interventions which are not routinely funded or commissioned by the local Clinical Commissioning Groups. The Clinical Triage Panel and the Case Review Committee is happy to consider an IFR if the clinician believes there is a strong case for a specific patient on grounds of an exceptional health need. You can read about exceptional health needs in section 8 of the Ethical Framework – March 2019.
The IFR process is not intended to be used to consider requests which, if funded, would be provided under NHS England specialised commissioning arrangements. NHS England operates its own IFR process. However, this policy takes into account the approach of NHS England in managing IFRs and, as far as possible, is aligned with the NHS England Interim Policy for Individual Funding Requests and the associated Interim Standard Operating Procedure.
2. Threshold Dependent Procedures (TDP)
TDPs are treatments/interventions which are routinely funded or commissioned when the patient meets the defined criteria for treatment.
Frequency of meetings for Case Review Committee/Panel
Case Review Committee/Panel will meet a minimum of six times a year. Additional meetings may be scheduled more frequently if needed, as indicated by request caseload and at the discretion of the CCGs.
Where necessary for reasons of expediency, virtual meetings will be carried out by telephone or email as necessary. These are not normally a substitute for routine meetings of the CRC but will be used only in unavoidable circumstances so as not to compromise the pace of decision-making for urgent individual cases. In such circumstances a decision will be taken on a consensus view; with the final decision endorsed by the Chair of the CRC and confirmed by the membership for the record.
Reconsideration of Cases
Cases can be reconsidered when ‘new’ additional clinical information is provided.
Appealing a decision
If you wish to appeal against a decision then the process that the case has been through will be reviewed and not the decision made.