There are some procedures/treatments that are not routinely funded or commissioned by NHS CCGs. Funding applications for these treatments are considered through the Prior Approval and Individual Funding Request (IFR) process and may be submitted by a clinician via email or on the online portal.
There are two main types of funding requests:
Prior Approvals (PA) – Procedures/treatments that require prior approval
PA is required for procedures/treatments which are routinely funded or commissioned when the patient meets the defined criteria for treatment.
Individual Funding Requests (IFR) – Procedures/treatments not routinely funded
IFR is required for procedures/treatments which are not routinely funded or commissioned by the NHS or local Clinical Commissioning Groups. The IFR Panel will 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 this guide: Exceptional Health Need – guide for patients and clinicians.
The IFR process 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. However, the IFR process will not consider any procedures/treatments under NHS England specialised commissioning arrangements as NHS England operates its own IFR process.
The process to be followed
All requests should be completed using the funding application forms or proformas that can be found on the relevant CCGs tab on this website, or by completing a proforma on the Blueteq online portal. The CPI Service does not accept any correspondence by post, and anything we do receive will be disposed of securely without processing.
All funding applications must be submitted by a patient’s NHS clinician.
The clinician requesting funding must ensure the funding form is completed accurately, as comprehensively as possible and submitted with the relevant supporting clinical evidence. This will ensure there are no delays in considering the funding 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. The requesting clinician can also include supporting information provided by the patient, but this must not be submitted directly by the patient.
The CPI Service will not accept direct patient requests, or routinely enter into any correspondence with patients and/or their families unless as part of the statutorily applied NHS Complaints Procedure. However, the team may provide guidance to patients (and their families subject to consent) regarding the process undertaken. 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.
If a patient, who has been treated privately, wishes to transfer their treatment onto the NHS their GP or healthcare professional should refer them onto the local NHS pathway for treatment. If a patient has opted to pay for treatment and/or procedures privately, these will not be funded retrospectively and would not normally include future treatment offered by the private provider.
The CPI Service will triage cases received and make decisions based on current policies found on the relevant CCG page.
IFR cases and cases that require wider discussion may go on to a Clinical Triage Panel, and then a Case Review Committee/IFR Panel meeting if required.
Reconsideration of Cases
Cases can be reconsidered when ‘new’ additional clinical information is available and provided by a clinician.
Appealing a decision
An appeal is where a check on the process, and not the decision made on the case, is reviewed.
The Appeals Panel’s remit will be to consider whether the process and rationale behind the IFR Panel’s decision-making have been adequately followed, that all relevant information has been considered and that the decision was fair, equitable and based on the evidence available at the time. It does not make funding decisions and, if any new evidence is brought before it, this must be referred back to the previous Panel.
The Appeals Panel will not accept appeals instigated by a patient, their family or other non-clinical representative (e.g. local MP).
For further information including the Terms of Reference for the above follow the links to the appropriate CCG