Individual Funding Requests (IFR)

IFRs are funding requests for a single identified patient suffering from a medical condition for which Coventry and Warwickshire Integrated Care Board (CW ICB) has commissioning responsibility and:

• CW ICB has no commissioning policy in respect of the treatment for which funding is sought
• the patient does not fulfil the criteria for eligibility for treatment set out in the policy
• CW ICB has a policy stating that it will not routinely fund the drug or intervention for any patient for a specific treatment not normally commissioned by the ICB

An IFR should only be submitted where the clinician believes 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:

1. There is no good evidence that a treatment is effective
2. 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 clinician 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. 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 clinician believes that 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.

The ICB expects the clinician to submit an IFR only if they know the individual circumstances of the patient that make them significantly different to other patients with the same condition.

The ICB expects secondary care clinicians to be responsible for the submission of an IFR if they believe there were aspects of the clinical details for the individual patient that make them an exception to the general rule. We would expect such an application to come from the secondary care clinician concerned not to be passed back to primary care to make the application.

 

About the IFR process

An IFR may be made for a treatment, therapy, drug or piece of equipment because:

• The ICB’s routinely commissioned services do not cover the patient’s situation or
• The ICB’s commissioning policy does not cover the patient’s situation

An IFR submission needs to demonstrate that the patient:

• Has exceptional circumstances relating to their 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 would constitute 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 ICB’s IFR panel:

• Demonstration of exceptional clinical condition
• Demonstration of exceptional benefit
• Effectiveness
• Equitable
• Evidence based

What is meant by ‘exceptional clinical circumstances’

NHS Coventry and Warwickshire ICB has clinical commissioning 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 exception may arise where a patient, who would not normally be eligible for treatment under an ICB clinical commissioning policy or commissioning arrangement, has factors about their clinical presentation that the clinician believes warrants special consideration.

Such cases are given particular scrutiny because not only does a decision to fund the requested care requires the ICB to find the necessary resources from other areas of care but if the patient were to have their treatment funded, the ICB would have to make the treatment available to other patients who have similar clinical circumstances.

This would require the ICB to agree a new clinical 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 presentation’ 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 AND
• 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.

If you require any further clarification or have a query regarding commissioning policies/arrangements please contact the IFR team.

For the funding request form, the policy and the patient leaflet, click here.