Every year, NHS Birmingham and Solihull Integrated Care Board (ICB) receives a set amount of money from the Government to pay for healthcare.
The ICB has a duty to spend this money in a fair and efficient way, taking into account the health needs of the whole local community, for which the ICBs have commissioning (funding) responsibility.
In some instances the clinician in charge of the care of the patient's specific condition, usually a hospital doctor may think the case is very different to other patients with the same condition and because of that difference, the patient may be able to have a treatment that is not normally funded. This is referred to as having clinically exceptional circumstances. Requests for this type of treatment must be made through an Individual Funding Request (IFR).
The patient cannot apply for funding themselves. It is the clinician in charge of the care of the patient's specific conditions responsibility to present the patient's exceptional circumstances and provide clinical evidence to support the request.
It is possible to make an IFR in the following situations:
- When the ICB does not have a policy stating who can have the treatment that is being requested
- When the ICB has a policy, but the patient's clinical circumstances do not meet the criteria for treatment
- When the ICB has a policy stating that it will not routinely fund the treatment
- When the patient has a rare medical condition that is not covered by a ICB policy.
What does exceptional mean?
The patient’s clinical circumstances may be considered to be ‘exceptional’ if:
- The patient has clinical features that makes the patient significantly different from other patients who have the same clinical condition.
The fact that a treatment is likely to be successful in producing the desired or intended result is not by itself an exceptional circumstance. The Panel has to consider if there is likely to be a group of patients:
- With the same or similar clinical circumstances, OR
- Whose clinical condition means that they could make the same request, OR
- Who could be expected to benefit from the requested treatment to the same or similar degree.
The Individual Funding Request Team will advise the patient's clinician in cases where a treatment is covered by an existing policy. If the request is not covered by an existing policy, or the patient falls outside the criteria of a policy, the request will be submitted to the weekly IFR Screening Panel. The request may be forwarded to the IFR Panel. They generally meet once a month. The IFR Panel includes at least one clinician.
The role of the IFR Screening Panel is to identify whether the patient's application and clinical circumstances demonstrate clinical exceptionality, in which case the application will qualify for review at the IFR Panel.
Decision making is based on the ICB’s Individual Funding Request Policy. We aim to make these difficult choices in a robust way which is fair, clear and consistent. If the Panel considers the request to be exceptional, it reviews the following criteria:
- Clinical effectiveness (If the treatment is likely to be beneficial and safe.)
- Cost effectiveness (How much it costs to achieve the health benefit predicted. The proposed treatment should be the most cost effective option that meets the clinical need.)
- Affordability (Resources used to support an individual patient will reduce the availability of resources for other treatments or services.)
- Exceptionality (Clinical exceptionality of the patient within the group/cohort of patients.)
Information submitted to the Panel is anonymised. Only the patient's medical condition will be considered as part of the IFR process. Social and personal circumstances cannot be taken into account. This is because everyone has their own individual value and role. These factors cannot set the patients case apart from that of another patient without implying that one patient is more deserving than another because of who the patient is or what the patient does.
If there are likely to be other similar patients who would also benefit from the requested treatment, the Panel cannot agree funding under the IFR process. In this instance the ICB may need to consider developing a case for change for a new service the evidence for which will be considered by ICBs prioritisation and commissioning investment/disinvestment process and may ask for the referring clinician to submit a Business Plan.
A letter stating the Panel’s decision and the reasons will be posted to the referring clinician and patient/parent/guardian within five working days of the IFR Panel.
Appeals can only be made if the patient or clinician feels:
- The IFR Panel did not follow the proper process
- The IFR Panel did not take all relevant evidence available to them into consideration.
The patient, legal guardian or clinician can appeal within three months of the original IFR Panel decision and request that the decision be reviewed. To ensure a fair process, all appeals will be considered by an IFR Appeals Panel, (this is a different panel to whom made the original decision). Unfortunately, the IFR Appeals Panel cannot consider new evidence, therefore if new evidence becomes available the patient's clinician may re-submit the application. If the patient's request has not been considered by the IFR Panel, there is no right of appeal.