|"An IFR is a request to fund, for an individual, an episode of healthcare that currently falls outside existing contracts. The funding request may be asking for any type of healthcare: a service, a piece of equipment or aid, a specific treatment or medicine. In contrast to annual prioritisation and inyear service development decisions, appropriate IFRs are considered on an individual patient, rather than population, basis. There are two main categories of appropriate IFR: first, where patients fall outside an existing generic or treatment-specific policy where an unusual circumstance applies to the individual; second, for patients with a very rare clinical condition" NPC 2009|
An "Individual funding request" or IFR is the process used by a NHS commissioning organisation to decide whether to make a funding arrangement for an individual for a particular, usually non-routine purpose, such as:
- A rare disease without other commissioning arrangements
- Where a conditions treatment is not routinely funded but a rare combination of clinical circumstances may make the individual circumstances exceptional eg:
- To pay for accommodation for a patient with tuberculosis, so that they can continue to take their treatment, and not become a public health hazard to others.
IFRs are assessed according to a local policy. Often an area larger than just one commissioning primary care organisation will partake in the standard process, particularly where routine commissioning decisions are aligned. Formal delegation is necessary by any commissioning group to any host commissioning group of such powers. Such arrangements have advantages such as decreasing administrative support and that rarity can be handled more consistently across the health economy. It can be confusing to identify the responsible commissioner although in England the manual gives the general guide.
The English NHS makes decisions on whether to routinely commission treatments on a population basis for a cohort of patients. This creates issues around the increasing ability to individualise treatment on a genetic basis, the cost benefit analysis being applied at potentially only at a defined point in the pathway of care, and unfair decision making. For example exceptionality is defined by the commissioner, sometimes in terms of the number of IFR requests received for a particular indication over a given time period, and an NHS commissioner does not commission for identical population sizes or consistent with other NHS commissioners unless the treatment and indication has been subject to a NICE technical appraisal or equivalent process where effectively commissioning becomes legally mandatory. As NHS England commissions for children and individual CCGs commission for adults it is quite possible for treatment access to be dependent on not just where you live, but the age you develop an illness despite no clinical evidence of differential response. A 2016 High Court case has determined that NHS England's process for determining exceptionality was perverse. This is likely to have general implications as the process for determining exceptionality applied by most commissioners is unlikely to meet the standards expected by the courts. For example currently decision making panels or the those involved in the screening process may lack appropriate specialist expertise. Also the possibility of an NHS funded individual trial of the drug to evaluate individual response is often precluded with current process. This decision is however only likely to apply where the cost of treating the exceptional case is not determined to be a factor by the commissioner.
Other issues include that commissioners may not have had time to formulate policies that ensure appropriate access to (new) treatments where treatment is clinically critically urgent, that easily meet usual NHS criteria for effectiveness. Much NHS decision making is deferred to an annual commissioning round and in year decision making is both minimised and bureaucratised. Indeed the High Court has observed that utilising bureaucratic processes to delay consideration based on a clinical update of an already submitted IFR was not appropriate.
- The regulations that now allow IFRs are the National Health Service Commissioning Board and Clinical Commissioning Groups (Responsibilities and Standing Rules) Regulations 2012 (2012 No. 2996). Under Part 7 "Standing rules: decisions about drugs and other treatments". A relevant body, .... must have in place arrangements for making decisions and adopting policies on whether a particular health care intervention is to be made available and those arrangements must include those for the determination of any request for the funding of a health care intervention for a person where there is no relevant NICE recommendation and the relevant body’s general policy is not to fund that intervention (paragraph 34). Reasons must be given for any decision (Regulation 35).
- Each IFR policy stands on its own.
- Exceptional clinical circumstances do not include non-clinical circumstances.
- It is lawful for an IFR decision to be considered and determined exclusively by reference to clinical factors.
- Appropriate cohort for determining exceptionality are not necessarily all with a condition (unless no treatment is commissioned for that condition) but might say be a subcohort such as those who do not respond to the usual treatment for a condition.
- Exceptional cannot mean unique. Rarity with in a cohort could apply where clear evidence existed that an individuals mental and physical health was suffering exceptionally compared to the reference cohort.
see for example: