Why is treatment not funded for everyone?
Your healthcare is paid for by the National Health Service (NHS). The budget for healthcare is given to various organisations to pay for your treatment. Locally, the Clinical Commissioning Group (CCG) is responsible for funding healthcare treatments for the population for which it is responsible. CCGs are allocated sums of money and have to make decisions to use the money for the healthcare needs of the population that they provide healthcare for. Unfortunately, there is not enough money to fund every possible type of operation, procedure and medication so decisions have to be made as to what will be available for everyone and what has to be restricted.
What type of decision-making principles are used when assessing an IFR?
We operate in the context of the South Central Ethical Framework, which stresses the need for decisions to be fair, consistent and equitable. All decisions are made after taking into account all of the following:
- The patient’s clinical need
- The effectiveness of the treatment
- The cost of the treatment
More information about the Ethical Framework and details of the processes, can be found at: www.oxfordshireccg.nhs.uk/about-us/how-we-work/priority-setting
Can you give examples of an Individual Patient Funding Request?
These requests can be for any type of healthcare, including a service, treatment, medicine, device, or piece of equipment. Usually, they fall in one the following categories:
- A patient would like a treatment that is new, being developed, or unproven. For example, a drug that has not yet been approved for use in that particular condition.
- A patient wants access to a treatment which is available in certain clinical circumstance, but not their individual circumstances. For example, a request for treatment for varicose veins.
- A patient with a rare or specialist condition that falls within specialist services, but does not meet the clinical criteria for treatment. For example, a request for plastic surgery.
- A treatment normally used for aesthetic surgery but for which a patient has a genuine clinical need. For example, a breast reduction.
Can patients get a ‘low priority treatment’ on the NHS?
NHS clinicians (GPs, hospital doctors and certain other health professionals) can ask the CCG to consider funding a low priority treatment for one of their patients.
Funding may only be approved if:
- There is something significantly different about the patient’s condition when compared with others with the same condition (who would not receive the requested treatment): AND
- As a result of the difference, the patient is likely to gain significantly more benefit from that treatment than would generally be expected.
There must also be sufficient evidence that the treatment is cost effective and that the cost of treatment does not outweigh the benefit gained (see CCG policy / Lavender Statement No. 80c).
Can I apply for funding myself?
No, this is not possible. All funding applications have to be submitted by either your GP or hospital consultant.
Can I attend the IFR Panel in person to put forward my case?
No, this is not possible. In order to be fair to all patients, as well as those that are unable to attend, we do not permit patients, carers or any representative of the patient to attend the panel.
Can I provide any evidence to support the application for my funding?
Yes, you can. You are able to provide a written statement of how your condition or illness impacts on your daily activities and quality of life if you wish. Please let your doctor know that you would like a letter from you to be sent with the application form. This will be added to your case file and reviewed by the IFR Panel.
How soon after the IFR Panel will I hear of the decision?
A letter will be sent to your clinician and usually to you within 2 weeks of the IFR Panel decision.
Will I have to pay anything if the funding is agreed for my treatment?
If the panel agree to fund your treatment, the NHS will pay for it. You will not need to pay anything.
How long do I have to wait after the Funding is agreed to receive treatment/medication?
If your funding request is approved, your GP or Consultant will make arrangements for you to have the treatment. How long you have to wait after the decision may depend on a number of factors including waiting lists, but your GP or Consultant will be able to advise you.
Can I pay for part of the treatment myself?
No, it is not possible to mix NHS and private funding. See Lavender Statement 67a.
My condition/treatment is normally commissioned by NHS England, but they have declined funding. Can I now apply to OCCG through your IFR process?
If your request for funding has been declined by NHS England, you cannot apply via your Clinical Commissioning Group’s IFR process. OCCG only consider funding requests for treatments that are commissioned by OCCG.
There is no Lavender (commissioning) Statement for my condition. Why is that?
If there is no Lavender Statement for your condition then EITHER it is a treatment that OCCG do normally commission (pay for), OR it is a new/experimental treatment and we may not yet have a Lavender (commissioning) statement.
Why will you not pay for a treatment that NICE recommends?
Clinical Commissioning Groups (CCGs) under the NHS constitution have a duty to provide treatment which NICE has recommended in the technology appraisals. Other guidance by NICE is advisory only. See the NICE website.