Exceptional requests for care surge as rationing deepens

The number of exceptional funding requests that GPs in England are making on behalf of their patients for treatments such as cataract removal, hip and knee replacements, and mental health interventions has increased markedly, an investigation by The BMJ has found.1

Richard Vautrey, a GP in Leeds and deputy chair of the BMA’s General Practitioners Committee, said that the figures were a sign that clinical commissioning groups were under increasing financial constraint. “There is undoubtedly more pressure on CCG budgets and attempts to reduce referrals and costs, and the greater use of IFRs [individual funding requests] may be one way some are trying to do this,” he told The BMJ.

Doctors made 73 900 individual funding requests to CCGs last year, a 47% rise from 2013-14, when they made 50 200, data collected by The BMJ under a freedom of information request show. In just the past 12 months the number of requests rose by more than 20%, from 60 400.

Just over half (52%) the requests made in 2016-17 were approved, but even patients who are granted access to treatment may have waited months for it.

Individual funding requests, which first emerged in England in the 2000s, are made by GP, consultants, or other health professionals for treatments that are not routinely funded in their area. Local panels convened by CCGs decide which to approve.

Most are for cosmetic procedures or fertility treatment. But GPs in some areas are now being told to apply for exceptional funding for a wider range of treatments.

Chiltern and Aylesbury Vale CCGs in Buckinghamshire recently told doctors that all referrals for hip and knee surgery must go through an individual funding request.23

Stephen Cannon, vice president of the Royal College of Surgeons, condemned the move as a misguided attempt to save money by reducing activity and urged the CCGs to reconsider the policy. “By mandatorily requiring prior approval from the IFR service before referral, these CCGs are unfairly and unnecessarily prolonging the time patients will spend in pain, possibly immobile and unable to carry out daily tasks or to work,” he said.

Vautrey called for “an open and honest discussion” on this type of rationing. He urged NHS England to set clear guidelines on which treatments should be routinely available and which should require an individual request. “It’s clearly unfair for patients to be subjected to this postcode rationing, and it also adds further to GPs’ workload as they are called on to provide more and more evidence to support each application,” he told The BMJ.

Julie Wood, chief executive of NHS Clinical Commissioners, the organisation that represents CCGs, said that commissioners had to make “difficult decisions” over which services to fund. “Unfortunately the NHS does not have unlimited resources, and ensuring that patients get high quality care against a backdrop of spiralling demand and increasing financial pressures is one of the biggest issues CCGs face,” she said.