YORKSHIRE AND THE HUMBER
Arrangements for the determination of requests for the funding of a health care intervention for an individual, where the Primary Care Trust’s general policy is not to fund that intervention 1.1 Primary Care Trusts (PCTs) make decisions about the funding of most interventions for their registered population. Such decisions are referred to as the ‘general policy’ for the intervention. 1.2 This document describes the arrangements for how the PCT deals with requests for an individual to receive a treatment where the general policy does not recommend funding. 2 Making an application 2.1 If a doctor1 treating a patient, after discussion with that patient, considers an intervention should be offered to the patient as part of their NHS care, they will first check if the intervention is funded as part of the general policy of the PCT. 2.2 If the general policy does not provide funding for the intervention and indication proposed, the treating doctor may want to ask the PCT to consider the individual case of the patient for funding (an individual funding request [IFR]). 2.3 The treating doctor should complete the standard IFR form. This should be sent to the PCT and copied to the patient’s GP. The PCT has an officer that can help with the process if this is required. 2.4 The PCT will first check to see if the requested treatment is funded as part of a general policy. If this is the case, the treating doctor will be advised of the general policy. 2.5 If it is not funded as part of a general policy, the PCT will consider funding the treatment through the individual funding request process (see below). If more information is required, an officer from the PCT will contact the doctor directly to request the additional information.
In this description, the word Doctor is used to describe the treating doctor. The PCT may consider requests from other professionals in certain circumstances.
3 The Individual Funding Request Panel 3.1 The PCT has a Panel which considers anonymised individual funding requests. 3.2 The decisions made by the IFR Panel are documented. 3.3 The Panelâ€™s decision may be to fund the individual request or not to fund the request. If a decision cannot be made, for example due to missing information, this will be made clear to the referring doctor and patient. 3.4 The Chair of the Panel, or designated officer, will inform the referring doctor of the decision and, if requested, a copy of this information will be sent to the patient and their GP. The patient should discuss the decision with either their treating doctor or GP. 3.5 If the decision is not to fund, the referring doctor and patient may ask the Panel to reconsider the decision in light of additional clinical information relevant to the request. This information should be sent to the PCT. 3.6 Relevant additional clinical information will be considered by the IFR Panel at a further meeting following which the Panelâ€™s decision may be to fund or not to fund the individual request. As before, the Chair of the Panel (or designated officer) will inform the referring doctor of the decision and, if requested, a copy of this information will be sent to the patient and their GP. 4 Appealing against a decision not to fund 4.1 Where a decision has been made by an IFR Panel not to fund a treatment, and the referring doctor feels that all relevant clinical information has been provided and considered, the patient or their doctor may want to appeal against the IFR Panel decision. 4.2 If an appeal is made, the PCT will refer it to its IFR Appeals Panel whose membership is different to the IFR Panel members who considered the original request. 4.3 The IFR Appeals Panel provides a procedural review of the IFR Panel decision. It considers whether the IFR Panel acted within its powers, and whether its decision was reasonable and fair. The IFR Appeals Panel has access to the all relevant documentation about the request but does not, in general, consider new evidence. 4.4 The IFR Appeals Panel may decide to uphold the original decision, to reverse it (that is, agree to fund the intervention), or to ask the IFR Panel to reconsider its decision. 4.5 The Chair of the IFR Appeals Panel, or a designated officer, will inform the referring doctor of the decision and, if requested, a copy of this information will be sent to the patient and their GP. 4.6 If the IFR Appeals Panel upholds the original decision not to fund an intervention, the patient may choose to complain about the decision within the NHS complaints procedure.