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NARRATIVE FOR GP GATEWAY RELATING TO INDIVIDUAL FUNDING REQUESTS (IFR) 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 Effectiveness Equitable 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 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. Clive Campion Individual Funding Request Lead NHS Arden Commissioning Support Westgate House, Market Street, Warwick CV34 4DE [email protected]