Individual Funding Requests

Overview:

Mid and South Essex (MSE) ICB receives a fixed budget from Central Government with which to commission healthcare services required by its population. Commissioned services include those provided through primary, secondary and tertiary care NHS providers, the independent sector, voluntary agencies and independent NHS contractors.

The commissioning process, by its very nature, focuses on cohorts of patients with more common clinical conditions. It cannot meet every healthcare need of all patients in any one clinical group or address the specific needs of patients with less common clinical conditions. The fact that a ICB is not meeting a healthcare need due to resource constraints is an inevitable fact of life in the NHS and does not indicate that that the ICB is breaching its statutory obligations.

ICBs are required to have a process for considering funding for individuals who seek NHS commissioned services outside established commissioning policies. There are, in general two types of requests (Category 1 and 2) that come before an Individual Funding Request (IFR) Panel, namely:

Category 1 – Requests for funding treatments for medical conditions where the ICB has no established commissioning policy (commonly called IFR requests), and

Category 2 – Requests for funding treatments for medical conditions where the ICB does have an established commissioning policy for that condition but where the requested individual treatment is not in the ICB policy or does not meet the criteria set out in the policy.

Information about how the panel makes these decisions can be found below and in our individual funding request policy.

Individual funding request proformas:

1 – Non-Drug – Individual Funding (docx, 136kb)

2 – Drug – Individual Funding (docx, 90kb)

Please email the individual funding requests team with any questions about the forms: [email protected]

The NHS exists to serve the needs of all patients but also has a statutory duty to break even financially (National Health Service Act 2006). Integrated Care Boards (ICBs) have responsibility to provide health benefits for the whole of their population, whilst commissioning appropriate care to meet the clinical needs of individual patients.

Demand for healthcare continues to grow and we must prioritise the most clinically and cost-effective treatments available. Decisions to fund new treatments mean less is available for other health services. Difficult choices must be made over the healthcare we can afford and those which benefits the most people. We try hard to make these choices in a way which is impartial, consistent, and fair.

A patient’s treating clinician (Either GP or Consultant) can request a review under our Individual Funding Requests (IFR) Policy if they are able to evidence clinical exceptionality.

The words “exceptional”, “exceptionality” and “exceptional clinical circumstances” bear their natural meanings as defined in the Oxford English Dictionary. However, the ICB recognises that the meaning of these words has given rise to considerable difficulty in the past and offers the following guidance to assist the IFR Team, Panel and clinicians as to how to approach the meaning of the words.

There is a difference between “individual” and “exceptional”. Every patient has features of their condition which are specific to that individual and are not likely to be repeated in other patients with the same clinical condition at the same stage of progression of the condition. Exceptionality is not the same as individuality.

To consider whether a patient has exceptional clinical circumstances the IFR Panel will focus on the following issues:

  • Are there any clinical features of the patient’s case which make the patient significantly different to the general population of patients with the condition in question at the same stage of progression of the condition?

AND

  • Would the patient be likely to gain significantly more clinical benefit from the requested intervention than might be normally expected for the general population of patients with the condition at the same stage of the progression of the condition?

Cases are initially dealt with and triaged by the Funding team who will advise the referrer whether the Service Restriction Policy (SRP), portfolio of contracts, Service Level Agreement (SLA), or current commissioning policies would cover the request.

The IFR Panel are a multi-disciplinary professional group responsible for making decision on IFRs when clear evidence of clinical and cost effectiveness/affordability have been identified within the patients case.