These are to be applied for if clinicians believe that there are particular features about their patient which mean that any general funding restrictions should not apply.
There are 2 main reasons why funding may not be available:
- There is no good evidence that a treatment is effective
- There is some evidence of effectiveness, but not enough to justify a general policy of providing a treatment
It is very unlikely there will be a decision to fund individual cases if there is no evidence.
If a doctor feels that there is new evidence to consider, this should normally be done as part of general commissioning discussions, but there may be rare occasions when there is a reason to ask for an early review using the IFR process.
We should be very rare and such requests would normally come from the secondary care provider, who will be expected to produce a detailed review of any new evidence they have which they feel should over-ride the existing policy.
If the primary or secondary care doctor feels there are particular issues relating to the individual patient of such significance that the general policy should be over-ruled an application may be made under IFR rules.
Normally we would expect that GPs would ask for – and submit documentation – for an IFR only if they know something of the individual circumstances of the patient that made them significantly different to other patients with the same condition.
We would normally expect secondary care doctors to be the ones applying for an IFR if they felt there were aspects of the clinical details for the individual patient that made them an exception to the general rule. We would expect such an application to come from the secondary care doctor concerned not to be passed back to primary care to make the application.
About the IFR process
An Individual Funding Request (IFR) may be made for a treatment, therapy, drug or piece of equipment because:
- The CCG’s routinely commissioned services do not cover the patient’s situation or
- The CCG’s commissioning policy does not cover the patient’s situation
An IFR submission needs to demonstrate that the patient:
- Has an exceptional clinical condition
- Is significantly different to the general population of patients with the condition in question
- Is likely to gain significantly more benefit from the intervention than might be expected for other similar patients with similar circumstances
- Is not part of a cohort of patients and, therefore, the request constitutes a service development and should be considered in the annual round of health service prioritisation
The basis for exceptionality:
- The fact that a treatment is likely to be effective for a patient is not, in itself, a basis for exceptionality
- If a patient’s clinical condition matches the “accepted indications” for a treatment that is not funded, the patient is, by definition, not exceptional
- The responsibility for demonstrating exceptionality lies with the requesting clinician, as support for the case should be based on clinical factors and not social factors
Basis of decision making by the CCG’s Individual Funding Request panel:
- Demonstration of exceptional clinical condition
- Demonstration of exceptional benefit
- Evidence based
What is meant by ‘exceptional clinical circumstances’
NHS Coventry and Rugby CCG has policies and commissioning arrangements, which describe how the available resources are shared between the treatments of a range of conditions.
In many cases these policies describe the group of patients in whom the treatment will be routinely available and, by definition, other groups of patients would not ordinarily be able to have the treatment.
An exceptional case may arise when a clinician finds a patient who would not normally be eligible for treatment under a CCG policy or commissioning arrangements but whom the clinician believes has factors about their case that mean that they warrant special consideration.
Such cases are given particular scrutiny because not only does a decision to fund the requested care requires the CCG to find the necessary resources from other areas of care but if the patient were to have their treatment funded, the CCG would have to make the treatment available to other patients who have similar clinical circumstances.
This would require the CCG to agree a new commissioning policy (or amend an existing one) setting out that the treatment was now available for a new group of patients and setting out how this group had been identified.
Therefore, to meet the definition of ‘exceptional clinical circumstances’ it must be demonstrated that the patient is both:
Significantly different clinically to the group of patients with the condition in question and at the same stage of progression of the condition for whom the treatment is not routinely available
Likely to gain significantly more clinical benefit than others in that group of patients with the condition in question and at the same stage of progression of the condition
In other words, it must be shown that the patient is very different from others in a group of patients with the same condition/stage of the disease and has clinical features that mean that they will derive much more benefit from the treatment/therapy/drug/equipment being requested.
Individual Funding Request Lead NHS Coventry & Rugby CCG Parkside House Coventry
Tel: 02477 710952
For Application Form for Individual Funding Request see shortcut on right