PCTs refusing more treatment requests

Patients are increasingly being expected to fight to gain access to treatment.

PCTs are not funding the fertility treatment cycle NICE recommends (Photograph: SPL)
PCTs are not funding the fertility treatment cycle NICE recommends (Photograph: SPL)

An investigation by GP has found that the number of individual funding requests submitted to PCTs rose by almost a fifth in the past two years (see box below).

Individual patient funding requests are made by GPs or consultants on behalf of patients for treatments that PCTs will not routinely cover.

However, fewer and fewer of these funding appeals are successful. The proportion approved has dropped by a fifth.

Funding Requests
  • All seven PCTs providing data on requests refused (rather than withdrawn) show increases in rejections.
  • Funding requests submitted to PCTs rose by 17 per cent from 2008/9 to 2010/11.
  • Over this period, 9,000 more requests were made, but 1,000 fewer requests were approved.
  • The rate of acceptance of requests has fallen from 59 per cent to 46 per cent.

Source: Freedom of Information Act responses from 103 PCTs in England

Individual funding requests are born out of the tension between PCTs' freedom to make individual decisions and the NHS Constitution's defence of patients' rights.

Unless a particular treatment has been recommended by a NICE technology appraisal, PCTs are allowed to decide not to fund particular therapies.

But this cannot be a blanket ban, the NHS Constitution says. PCTs 'must consider exceptional individual cases where funding should be provided'.

Savings
The Audit Commission has estimated the NHS in England could save £500 million a year if it cut its use of low clinical value treatments. The money saved by cutting spending on unnecessary or cosmetic treatments could then be spent on more clinically effective treatments.

However, many PCTs go well beyond restricting treatments of low clinical value.

Bariatric surgery is one area where PCTs have particularly targeted funding restrictions, and around one in 10 of the funding requests relate to this.

Hertfordshire GP Professor David Haslam, chairman of the National Obesity Forum, says PCTs in many parts of the country are imposing criteria for bariatric surgery that go beyond those set by NICE.

'PCTs are putting barriers in the way of NICE guidance,' he says. 'Patients have the NHS Constitution and NICE guidance to fall back on. But it is a major problem.'

Fertility treatment
By far the most common area for individual funding is fertility treatment, making up around 20 per cent of requests.

NICE has recommended that eligible couples should receive three full cycles of treatment, but many PCTs are not making this available.

Susan Seenan, of patient group Infertility Network UK, says she is 'extremely concerned' that couples have to fight for funding for fertility treatment. 'Refusing to accept new referrals for couples suffering from infertility flies in the face of good clinical guidance.'

Individual patient requests are not limited to expensive interventional procedures. Around 10 per cent of requests submitted to PCTs relate to treatments for wet age-related macular degeneration (AMD).

Restrictions on funding for treatments
The Royal National Institute of Blind People says individual requests should not have to be made for those eligible for NICE-approved treatment.

Barbara McLaughlan, policy and campaigns manager, says: 'Wet AMD can be a very aggressive disease and having to wait for a funding decision leaves patients vulnerable to irreversible sight loss.'

Patients are also having to rely on individual requests for other NICE-approved interventions, including diabetes education and insulin pump therapy.

Stella Valerkou, senior policy officer at Diabetes UK, says it would 'be very worrying and short sighted' if PCTs were restricting access to clinically effective treatments on cost alone.

'All people with diabetes must have equal access to effective treatments based on individual clinical need, not on the NHS's ability to pay,' she says.

'Effective treatment reduces the risk of costly and devastating long term complications of diabetes.'

Ms McLaughlan says patients also face problems when no NICE guidance has been developed for an area, such as for the treatment of cataracts. Funding applications then have to be made without NICE guidelines to back them up.

'Under restrictive policies more patients who do not meet new PCT criteria have to apply for individual funding,' she says.

'Often their chances of success are slim because they belong to a large patient group and can't prove that they would benefit more than others.'

Professor Haslam believes GP consortia will have their work cut out if they are to improve on the uncomfortable decisions that PCTs have had to make.

'With GP commissioning things may get worse,' he says.

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