Trends in NHS funding: individual funding requests
You have a patient who you believe will benefit from a medicine that is not routinely funded by their primary care trust. Here we look at how such individual funding requests can be handled by hospitals
The NHS Constitution for England states that patients have the right to drugs and treatments recommended by the National Institute for Health and Clinical Excellence, if clinically appropriate.
For other treatments, patients have the right to expect local decisions on funding to be made rationally following proper consideration of the available evidence.1
In this second article on NHS funding mechanisms, we look at how providers — in this case hospitals — can use individual funding requests (IFRs) to secure payment from primary care trusts in such special circumstances.
We also describe the IFR process used at Leeds Teaching Hospitals NHS Trust (LTHT) — which is co-ordinated by the pharmacy department (see Box below).
A local approach to individual funding requests
The individual funding request (IFR) process at Leeds Teaching Hospitals NHS Trust is co-ordinated by the pharmacy department. Through this central “hub” (identified as good practice in the National Prescribing Centre handbook3) pharmacists work with clinical teams to identify whether or not an IFR is appropriate and has followed trust policy, such as having support from the drug and therapeutics committee (DTC). As agreed with our local PCTs, IFRs will only go through the system if they have DTC support.
Through this advisory role we have developed a patient information leaflet to facilitate discussions between clinicians and patients around the process and why it exists and guidance on what is required for an IFR application. This guidance emphasises that PCTs require the right information and evidence from the clinical experts requesting treatment to allow a rational decision to be made.
A standardised IFR form has been developed, in consultation with local PCTs, to ensure a consistent data set is used, with the aim of all applications providing the same level of information. This form provides the basis for a locally developed database that contains all information for each IFR. The screen shot below illustrates the kinds of data sets within the database.
Each IFR is reviewed by a pharmacist before it is submitted to the PCT to ensure it contains sufficient clear information to allow the PCT to make a rational decision.
The IFR is then linked to the appropriate DTC submission with meeting minutes and a weblink to any relevant commissioning positions (eg, National Institute for Health and Clinical Excellence guidance or draft guidance, local policy, recommendations from other advisory bodies such as the Scottish Medicines Consortium). All identified information is sent to the patient’s PCT through an automatically generated email via the database.
Decisions are also documented and communicated through the database to keep an accurate trail of information and to notify clinicians of decisions as soon as they are available.The database can be used to obtain statistics on workload, IFR outcomes and common IFRs that may require policy development. Below is an example of such information.
IFRs 1 April 2009 to 31 March 2010
Total number of IFRs = 313*
Total number of different medicines or indications = 103
Total number of PCTs approached:
Within Yorkshire and Humber = 13 (304 applications; 170 for Leeds)Outside Yorkshire and Humber = 8 (9 applications)
Total (and percentage of total)
As initial decision
|Number of IFRs approved||280 (89%) ||255 (91%) ||25 (9%) |
|Number of IFRs not approved||25 (8%) ||15 (60%) ||10 (40%) |
|Number of IFR decisions deferred||6 (2%) |
|Number of IFRs no longer applicable||2 (1%) |
|*Compared with 406 in the previous year |
To support such local decision-making about medicines the Department of Health commissioned the development of guiding principles, published in January 2009. The purpose of these is to improve the consistency and quality of local decisions and reassure patients that there is a common, rational framework within which decisions are being made.2
The National Prescribing Centre developed these principles further to produce a handbook of good practice guidance to help PCTs and hospitals create their own systems and processes to meet the requirements of the NHS Constitution.3
In all of these documents was the overarching theme that PCTs should have a set of commissioning policies to cover decisions on most medicines while recognising that there will still be some requests for medicines not covered by these policies. IFRs may trigger the development of future PCT policies but in the interim systems need to be in place to allow sound decision-making.
IFRs have been used by hospitals to request that PCTs consider funding the use of a medicine for an indication that falls outside the range of services and treatments the PCT has agreed to commission4 (ie, not approved by NICE or covered by local policy). This route is used for medicines excluded from Payment by Results (in most cases these are DH-defined high-cost drugs).
The first article in our series introduced the concept of these high-cost “non-tariff” medicines (Clinical Pharmacist 2010;2:201).
When is an IFR appropriate?
All PCTs should have a policy outlining when they consider an IFR to be appropriate. The Yorkshire and Humber Specialised Commissioning Group (made up of representatives from 14 PCTs in that region) considers an IFR to be appropriate if either of the following applies:5
- The PCT has a general policy not to fund a healthcare intervention for the specified indication but a doctor considers his or her patient to be “exceptional” to that policy
- The PCT has no policy in place for the requested healthcare intervention and indication and the clinical circumstance is so rare that it is unlikely that any other patient will require the intervention
So what makes an individual patient exceptional? Exceptionality is essentially an equity issue around how a PCT can justify funding treatment for one patient when others from the same patient group are not being funded.
A common exceptionality definition used is: where a patient is significantly different from other patients with the condition in question and he or she is likely to gain significantly more benefit from the intervention than might normally be expected for patients with that condition.2,3
To be able to define a patient as “exceptional”, a policy must first exist. As identified in an NHS Confederation priority-setting document,4 hospitals without policies or alternative commissioning arrangements in place will find themselves in the position where the IFR route is the only one available to apply for funding of PbR-excluded medicines.
Working with local PCTs
There are many ways hospitals and PCTs can work together to ensure consistency of decision-making and, ultimately, reduce the need for IFRs. Clear lines of communication are needed; at LTHT we have found that information-sharing and transparent processes have helped us to develop good working relationships with our local PCTs.
To support local decision-making the pharmacy department at LTHT undertakes an annual horizon-scanning exercise to feed into the trust’s annual business planning process. This aims to identify medicines that may impact on the health economy in the coming year.
The information is shared with local PCTs, which can use it to inform population-based commissioning decisions to avoid the need for IFRs.
In line with the NHS Constitution, PCTs should make robust decisions — both for IFRs and when producing policies — using all the available information. It is important that hospitals recognise this and take responsibility for ensuring up-to-date, relevant information is provided by the clinical experts requesting funding support for medicines for specific indications.
As members of our PCT IFR panel, pharmacists are able to clarify existing information and provide further details on behalf of our hospital clinicians on specific cases, where these are available or deemed necessary. Locally this process has enabled more timely decision-making.
The pharmacy team also deals with requests for clarification or further information regarding IFRs generated by LTHT for patients from other PCTs.
More than ever, investments in healthcare interventions and services need to be planned to meet the needs of patients locally and respond to financial pressures.
Collaboration between PCTs and hospitals is key when planning changes to treatment pathways that include new medicines likely to have a substantial clinical and financial impact. Horizon-scanning provides information to allow more proactive commissioning decisions that are population-based.
The move towards proactive decision-making through annual service reviews and business case development — minimising the need for IFRs — is supported by the DH, the NPC and the NHS Confederation.2–4
It is hoped that IFRs will become the exception rather than the norm, for those patients who are exceptional to defined policies or the truly rare cases.
Helen Thorp and Catherine Hughes are medicines finance and commissioning pharmacists at Leeds Teaching Hospitals NHS Trust.
1 Department of Health. The NHS Constitution for England. March 2010. www.dh.gov.uk (accessed 23 June 2010).
2 National Prescribing Centre and Department of Health. Defining guiding principles for process supporting local decision making about medicines. January 2009 (accessed 23 June 2010).
3 National Prescribing Centre. Supporting rational local decision-making about medicines (and treatments). A handbook of good practice guidance. February 2009. www.npc.co.uk (accessed 23 June 2010).
4 The NHS Confederation, Primary Care Trust Network. Priority setting: managing individual funding requests. 2008. www.nhsconfed.org (accessed 23 June 2010).
5 Policy for individual funding requests. Yorkshire and Humber Specialised Commissioning Group. August 2009. (Microsoft Word document) (accessed 23 June 2010).
Citation: Clinical Pharmacist URI: 11017078