B/08/056 
 
 
  
 
 
 
 
 
Report to: 
Nottinghamshire County Teaching PCT Board 
 
 
 
 
Date of meeting: 
22 May 2008 
 
 
 
 
Title of paper: 
Policy on the Management of Named Patient Funding 
Requests 
 
 
Brief outline of content: 
 
The Individual Case Review Committee has been operational for approximately 1 
year working to the existing terms of reference.   
 
The paper comprises a revised policy and procedure for the management of Named 
Patient Funding Requests and the functioning of the Individual Case Review 
Committee (ICRC).  Processes for asking for a case to be reconsidered and for 
appeal are also clearly established. 
 
The ICRC has spent a good deal of time considering how processes can be more 
reflective of the patient voice.  Improvements to the proposed policy for consideration 
today include: better and more direct correspondence with the patient following the 
committee meeting, the consistent use of patient information leaflets, the facility for 
patients (supported by their clinician) to make an application and, importantly, the 
inclusion of a new role of ‘Lay Assessor’ who will be a voting member of the ICRC. 
 
Key aspects of the policy (including the schedule of low priority procedures and the 
PCT decision-making principles) have been consulted upon with three patient 
involvement groups.  The over-riding issue of concern for the involvement groups is 
that the PCT is seen to be consistent with neighbouring PCTs to guard against the 
accusation of ‘postcode’ healthcare. 
 
The East Midlands Specialised Commissioning Team will take over responsibility in-
year for commissioning some services covered by this policy.  The East Midlands 
Group are currently developing policies on Assisted Conception and Gender Re-
assignment, for example.  The Board is asked to approve this policy with the 
appendices A, F and J as interim PCT policies – to be replaced with immediate effect 
by the East Midlands policies, once these become available, following consultation on 
an East Midlands-wide basis.   

---

 
Legal advice has been sought on the policy and the advice received has been 
incorporated into the revised policy presented today. 
 
Two NHS Confederation documents on Priority Setting (‘Managing Individual Funding 
Requests’ and ‘Legal Considerations’) have been consulted in the development of 
this policy. 
 
 
Risk management implications (nature and level of risk mitigated and / or 
assurances provided by the report): 
 
•  The PCT’s reputation is at risk if this PCT is seen to be out of step with 
commissioning policy generally and could be accused of ‘postcode 
healthcare’.  This policy – inline with many others across the East Midlands 
and beyond will mitigate that risk. 
•  The PCT is at risk of challenge (up to a judicial review) if there are not 
appropriate policies and procedures in place for the handing of requests by 
individuals for treatment that the PCT would not normally fund.  This policy 
mitigates that risk and legal advice has been obtained. 
 
 
Financial impact of proposals: 
 
A separate report indicates the financial implications of this area of work. 
 
 
Patient & Public Involvement in relation to proposals: 
 
Three patient involvement groups have been consulted. 
 
 
Equality & Diversity impact: 
 
Equity, Equality and Diversity are considered as a key dimension of each case when 
deciding whether the case should be funded. 
 
 
Related mandatory / statutory requirements / legal issues / previous relevant 
decisions: 
 
  The Low Priority Treatments and Procedures policy (July 2007)  
  Policy on Assisted Conception (September 2008) 
  The ICRC Terms of Reference (November 2007, January 2008)  
 
have previously been considered by the board. 
 
 
 
Future monitoring / review arrangements: 
 
The Policy will be reviewed in May 2009 
 
 

---

 
 
Person presenting paper  Chris Kerrigan, Director of Commissioning and 
(name / title): 
Performance 
 
 
 
Originator of paper 
Deborah Jaines, Deputy Director, Commissioning and 
(name / title): 
Performance 
 
 
 
The PCT Board is recommended to: 
 
  APPROVEthe policy on the Management of Named Patient Funding 
Requests. 
  APPROVE the appendices A, F and J as interim until the introduction of 
East Midlands policies, which will replace the above appendices 
automatically following consultation by EM Specialised Commissioning 
Team. 
  AGREE to the inclusion of Lay Assessors as members of the ICRC. 
 
 
 
 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
POLICY  
ON THE MANAGEMENT OF  
NAMED PATIENT FUNDING REQUESTS  
 
 
 
 
 
Completed:  
April 2008 
Review Date:  
31 May 2009 
 
 
Board Approved:    22 May 2008 
 Effective from: 
1 June 2008 
 
 
 
     
 
1 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
  
Title of document  
Policy on the Management of Named Patient Funding requests 
Type of document   Policy 
Description 
This policy sets out the eligibility criteria for patients to receive NHS 
funding for services for which there is no established Service Level 
Agreement – or – where a treatment is considered to be ‘Low 
Priority’ for funding. 
Target audience  
Patients, Providers & Primary Care Independent Contractors 
Author  
Deborah Jaines, Deputy Director, Commissioning and Performance 
Directorate  
Commissioning and Performance 
Approved by  
PCT Board 
Date of approval  
22 May 2008 
Next review date  
31 May 2009 or before if any new guidance or clinical evidence 
becomes available. Appendices to be replaced in-year by specific, 
related East Midlands Specialised Commissioning Group policies 
(in development) 
Related 
PCT Cosmetic Plastic Surgery Policy 
documents  
PCT Assisted Conception Policy (East Midlands Policy in 
development) 
East Midlands Policy on the Management of Gender Dysphoria 
Superseded 
Low Priority Treatment and Procedures Policy July 2007 
documents  
Required action 
Individual Case Review Committee and relevant Commissioning 
staff to apply the policy and eligibility criteria as appropriate 
Internal 
Individual Case Review Committee members, Governance 
distribution  
Committee, Director of Public Health, Communications, PALS and 
Complaints Managers 
External 
Acute Providers, Primary Care Independent Contractors, East 
distribution  
Midlands Specialised Commissioning Team, Patient & Public 
Involvement Groups 
Availability  
Shared network drive 
Intranet site (PCT staff) 
 
     
 
2 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
Internet site (general public)   
 
     
 
3 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
CONTENTS 
 
1. 
Introduction  
Page 5 
 
2. 
Background  
Page 6 
 
3. 
The Process 
Page 6 
3.1  General Named Patient Funding Requests 
 
Page 6 
3.2   Assisted conception treatments  
Page 9 
3.3  Cosmetic Plastic Surgery Procedures 
Page 10 
3.4 Reporting 
Page 10 
 
4. 
Individual Case Review Committee Meetings 
Page 10 
4.1  Requests for funding 
Page 10 
4.2  Reconsiderations of requests for funding 
Page 11 
4.3 Appeals 
Page 11 
 
5.  
Specific Issues 
Page 13 
5.1 Co-Funding 
 
Page 13 
5.2  Continuation of Private Treatment 
Page 13 
5.3 Second Opinions 
Page 13 
5.4  Claim for Expenses 
Page 13 
5.5  Access to/Requirement for Psychological 
Page 14 
assessment 
 
5.6  Exceptionality - definition 
Page 14 
5.7  Support for decision-making 
 
Page 14 
 
 
 
APPENDICES 
 
 
Appendix A 
Schedule of ‘Low Priority’ Treatments 
 
 
Appendix 
B 
Nottinghamshire County PCT Request for   
Named Patient Funding form 
Appendix C 
PCT decision-making principles 
 
Appendix D 
Schedule of future meetings of the Individual   
Case Review Committee and Standard 
response times 
Appendix E 
Request for Named Patient Funding Flowchart
 
Appendix F 
Policy on Assisted Conception 
 
Appendix G 
Terms of Reference for the Individual Case   
Review Committee 
Appendix H 
Terms of Reference for the Appeals Panel 
 
Appendix 
J 
Commissioning Policy – Cosmetic Plastic   
Surgery Procedures 
 
     
 
4 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
POLICY ON THE MANAGEMENT OF NAMED PATIENT FUNDING REQUESTS 
 
(INCLUDING OUT OF AREA TREATMENTS (OATS) AND OTHER TREATMENTS, 
INTERVENTIONS AND NHS COMMISSIONED CARE, INCLUDING WHERE THE PCT HAS 
STIPULATED PRIOR APPROVAL IS REQUIRED) 
 
1. INTRODUCTION 
 
1.1 
The NHS exists to serve the needs of all of its patients but also has a statutory duty 
financially to break even. (National Health Service Act 2006).  Primary Care Trusts (PCTs) 
have a responsibility to provide health benefit for the whole of their population, whilst 
commissioning appropriate care to meet the clinical needs of individual patients.  It is 
important, therefore, that the PCT has a clear process for commissioning treatments for 
those patients with rare conditions, those patients for whom treatments of uncertain or 
unproven medical benefit are sought, or where treatment costs requested may be out of 
proportion with the benefit to the patient. 
 
1.2 
Each Primary Care Trust is responsible for the management of Named Patient Funding 
Requests, which would include requests for aspects of care which are specifically outside 
service agreements, where cases need assessment against existing policies (e.g requests 
for ‘Low Priority’ treatments) and where treatments are proposed that are not considered to 
be ‘mainstream’ and already established in Service Level Agreements with providers. 
 
1.3 
Many of the requests for individual treatments that fall outside of the scope of existing 
contracting arrangements will, by their nature, be difficult to resolve.  In reaching a decision, 
the PCT needs to take into account the rights and needs of the individual, the duties and 
responsibilities of the NHS, and to ensure that decisions are made in a consistent, fair and 
transparent manner.  The PCT will not make decisions based on personal characteristics, 
such as age, gender, sexual orientation, race, religion, lifestyle, social position or financial 
status, intelligence, disability, physical or cognitive functioning.   In short, social value 
judgements will not inform or affect decision-making. 
 
1.4 
A consistent process and criteria must be adopted across the Primary Care Trust to 
assess, review and monitor individual Named Patient Funding cases/requests.  It is the role 
of the Individual Case Review Committee – a formally constituted committee of the PCT 
Board – to fulfil this function. 
 
This system should ensure that all patients’ needs are considered equitably and a clear 
process is adhered to. 
 
1.5 
The term ‘Named Patient Funding Requests’ (NPFR) will be used to refer to all non-
contract treatments, out of area treatments (OATs) and other treatments, interventions and 
NHS commissioned care where the PCT has stipulated prior approval is required.  (The 
principal treatments that are excluded from contracts, and which the PCT would not 
normally fund, are set out in the Schedule of Low Priority Treatments – APPENDIX A and 
the schedule of cosmetic plastic surgery procedures – APPENDIX J). 
 
1.6 
Increasingly, the East Midlands Specialised Commissioning Team is developing a range of 
collaborative commissioning policies on behalf of all East Midlands PCTs.  Once 
developed, a number of these will directly relate to some of the services covered by this 
policy.  Once adopted by the East Midlands Specialised Commissioning Board, 
Nottinghamshire County teaching PCT will adopt the commissioning policies of the East 
Midlands Specialised Commissioning Board to ensure coherence with neighbouring PCTs 
and to minimise exposure to claims of ‘postcode’ healthcare. 
 
     
 
5 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
 
 
2. BACKGROUND 
 
2.1 
The PCT commissions the majority of treatment, investigations, interventions and care 
through agreed contracts with providers. (The term ‘services’ will be used to cover 
treatment, investigation, intervention and NHS commissioned care). Payment by Results 
(PBR), ‘choice’, with national tariff for many services has increased the range of providers 
accessed by patients. Pre-arranged service agreements are also widely used. However, 
many services are not included in ‘tariff’ and PBR or any other pre-arranged service 
agreements. Also, commissioners have stipulated that some services included in tariff also 
require prior approval.  
 
2.2 Examples 
include: 
 
•  New, often high cost drugs, some unlicensed. Examples include cancer drugs and 
disease modifying drugs for auto-immune disorders. 
•  Existing high cost drugs excluded from tariff (e.g. growth hormone). 
•  Treatments, usually high cost, excluded from tariff. (These are set out in individual PCT 
SLAs)  
•  Devices, usually high cost, either excluded from tariff or for use in the community where 
tariff does not apply.  
 
 
3. THE 
PROCESS 
 
As a formally constituted committee of the PCT Board, the Individual Case Review Committee will 
have ultimate authority to determine whether funding should be provided. The process will be:  
 
3.1 
General Named Patient Funding Requests 
 
New Requests 
 
a)  Requests for funding (which must be supported by an NHS clinician) will be submitted to 
the Individual Case Review manager, based at Ransom.  Requests will be received – 
usually on the standard application form (APPENDIX B), date stamped and processed by 
the Individual Case Review manager who will act as the custodian for requests.   
 
b)  The support of the patient’s treating clinician should be explicit, as they will be required to 
act as gatekeepers by informing patients of known policies and procedures currently in 
place.  Therefore, requests will only be accepted from the clinician responsible for 
managing the proposed treatment being requested.   
 
c)  Any requests received directly from a patient will be acknowledged and a letter will be sent 
to the patient advising them to contact their clinician to make a request on their behalf.  
Requests will not be accepted from a private clinician unless they are acting under contract 
with the NHS. 
 
d)  Clinicians making a request must provide all relevant clinical, evidential and personal 
information prior to the case being heard by the Individual Case Review Committee, by 
completing the Nottinghamshire County PCT Request for Named Patient Funding form 
(APPENDIX B).  Incomplete forms will be returned to the referrer. 
 
 
     
 
6 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
e)  All requests will be logged onto the Individual Case Review database, which will have 
restricted access and will be maintained to an agreed standard for logging and updating 
information on requests.   
 
f)  The Individual Case Review Manager will check the database for previous requests relating 
to each treatment request.  For all new cases a new entry in the database will be made, 
and a unique case number assigned.   
 
g)  The Individual Case Review Manager will create a new patient file record for the request, or 
add new details to an existing patient file.  File records will be created and maintained and 
stored to agreed standard ensuring patient confidentiality.  
 
h)  The Individual Case Review Manager will create and log patient details on a new “Decision 
Record” form.  
 
i)  The Individual Case Review Manager, will ensure that the request form has been fully 
completed.  Incomplete forms will be returned to the referrer for additional information.  
 
j)  The Individual Case Review Manager will check whether there is an existing 
policy/agreement that covers the treatment requested.     
 
k)  If an agreement exists, the Individual Case Review Manager will check whether the criteria 
within the agreement can be applied. 
 
l)  Where the criteria require clinical advice to establish eligibility, the Individual Case Review 
Manager will seek advice of the designated Public Health representative and, if necessary, 
the relevant senior manager in the Commissioning and Performance Directorate. 
 
m) If a decision can be made at this point (based on a demonstration of meeting or not 
meeting the clinical criteria), the decision record should be completed and a letter prepared 
for a response to be sent to the referrer, together with details of the appeals process in 
cases where the request is refused.  Where appropriate, the decision will also be copied to 
the patient’s GP.  Where appropriate, consistent with NHS Guidance on copying letters to 
patients, the decision will also be copied to the patient. 
 
n)  The database will then be updated and will include costs where agreement for funding is 
given.  Decisions taken outside of the committee meeting in this way, will be taken 
for noting to the next meeting of the Individual Case Review Committee meeting. 
 
o)  Where there is no existing policy/agreement, the Individual Case Review Manager will pass 
the request to the relevant Commissioning Lead to establish: 
 - Whether there is an existing contract/agreement that covers the request. 
 - Whether there is a suitable existing alternative local service that covers the request. 
 - Gather further information where necessary to inform decision-making. 
 - Obtain clinical/public health advice to inform decision-making. 
 
p)  If a decision can be made at this point, the decision record should be completed and a 
letter prepared for a response to be sent to the referrer, together with details of the appeals 
process in cases where the request is refused.  Where appropriate, the decision will also be 
copied to the patient’s GP.  Where appropriate, consistent with NHS Guidance on copying 
letters to patients, the decision will also be copied to the patient. 
 
 
     
 
7 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
q)  The database will then be updated and will include costs where agreement for funding is 
given.  Decisions taken outside of the committee meeting in this way, will be taken 
for noting to the next meeting of the Individual Case Review Committee meeting. 
 
In summary, the Individual Case Review Manager (in consultation with the Deputy Director and 
Consultant in Public Health) has four possible options for the management of each case: 
•  to approve on the basis that either the circumstances are so similar to a previous case(s) 
considered by the ICR Committee that their approval of funding is inevitable, or that the 
treatment is actually covered by main stream commissioning. 
•  to refuse funding on the basis again that the circumstances are so similar to a previous 
case(s) considered by the ICR Committee that their refusal of funding is inevitable, or that 
existing policy clearly directs that funding would not be granted, or that it is obvious that 
special circumstances do not exist. 
•  to determine that insufficient information has been presented within the application to 
enable a funding decision to be made. 
•  to refer the application to the ICR Committee 
 
If the Individual Case Review Manager refuses funding, then the clear right of "appeal" to the ICR 
Committee remains as set out in section 4.2 of this policy 
 
r)  Where no decision can be made at this point, the request will be referred to the 
Individual Case Review Committee for a decision.  The Committee will meet on a 
monthly basis and decisions will be made based either on the PCT individual requests for 
funding – decision making principles (APPENDIX C) or specific agreed policy where this is 
available.  (Such policy could be obtained either from the East Midlands Clinical Priorities 
Board or from the East Midlands Specialised Commissioning Team). 
 
s)  Cases referred to the Individual Case Review Committee should, wherever possible be 
heard at the next scheduled meeting of the Committee from the date the referral was 
received by the individual Case Review Manager.  Due consideration should be given to 
the clinical urgency of each request and should be processed appropriately.  Standard 
response times are set out in APPENDIX D. 
 
t)  Clinically urgent requests (where a patient’s health may be seriously adversely affected if a 
decision is not taken before the next scheduled meeting of the committee) will be dealt with 
outside of the Committee, if necessary, by the Deputy Director of Commissioning and 
Performance, the designated public health lead and the Committee Chair.  Decisions 
taken outside of the committee meeting in this way, will be taken for noting to the 
next meeting of the Individual Case Review Committee meeting. 
 
u)  Upon receipt of a request for named patient funding, the Individual Case Review Manager 
should request a review of the treatment requested by contacting either the designated 
Public Health lead, the Chief Pharmacist, other staff able to assist with research and by 
contacting East Midlands specialised commissioning team, as appropriate. 
 
v)  The Individual Case Review manager will check the database for previous cases.  Where 
these exist, a note on the decisions made with reasons for this will be provided to the 
Individual Case Review Committee. 
 
w)  The PCT Cancer Commissioning Lead will be consulted as part of the assessment process 
for all requests for cancer treatments.  This will ascertain whether the requested treatment 
has been approved by either the Cancer Network Board or the Chemotherapy sub-group.  
Where necessary, the Cancer Lead will bring all appropriate requests for decision to the 
 
     
 
8 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
Individual Case Review Committee for consideration.  Where it is likely that an emergent 
treatment for cancer is likely to be of benefit to a number of patients, the established cancer 
groups (Cancer Network Board and the Chemotherapy sub-group) will be asked to prioritise 
and present a business case to the PCT for consideration for funding and, if approved, all 
affected patients will have an ability to benefit. 
 
x)  The process/flowchart for assessing general requests is outlined in APPENDIX E. 
 
Monitoring 
 
a) A process for monitoring cases will be established to ensure that further information is 
pursued on a timely basis, and where this is not forthcoming, that cases are closed and 
referrers are informed. 
 
b) For routine cases, where further information is required in order to inform a decision, a 
reminder letter will be sent where this has not been received after 2 weeks of the first 
request, a second reminder letter will be sent after 4 weeks and a final letter with a cut off 
date of 8 weeks from the first request will be sent after 6 weeks.  The case will then be 
closed and notification sent to the referrer. 
 
c) Information may be requested from the referrer, Public Health, commissioning leads or 
other sources.  Where in-depth research is required which exceeds 8 weeks, cases will be 
brought to the next meeting of the Individual Case Review Committee for a decision to be 
taken with the evidence available in order to ensure that patients are not kept waiting for a 
decision for an unreasonable length of time.  This is for non-urgent requests only. 
 
d) Any further information on existing cases that is requested and received will be updated on 
the database, and a file note entered into the patient’s record. 
 
e) This information will then be passed to the Individual Case Review Manager for review and 
will be considered at the next meeting of the Individual Case Review Committee, where 
appropriate. 
 
f)  All communication relating to cases either written or verbal will be fully documented and 
added to patient case file in chronological order. 
 
 
3.2 
Assisted Conception Treatments 
 
a) The Individual Case Review manager will receive and assess all requests for assisted 
conception treatments against the current policy on assisted conception.  (APPENDIX F) 
 
b) The request will be logged onto the appropriate database, which has restricted access. 
Patient records are filed in a locked filing cabinet. 
 
c)  The decision will be relayed to the referrer.  Where appropriate, the decision will be copied 
to the patient’s GP. Where appropriate, the decision will also be copied to the patient. 
 
d)  Where the patient does not fulfil the PCT criteria for funding for assisted conception and the 
clinician requires the request to be assessed as an exception, or where there is uncertainty, 
cases will be referred to the Individual Case Review Committee for consideration. 
 
 
     
 
9 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
e) The decision will be relayed to the referrer, together with details of the appeals process in 
cases where the request is refused. Where appropriate the decision will be copied to the 
patient’s GP. Where appropriate, the decision will also be copied to the patient. 
 
 
3.3 
Cosmetic Plastic Surgery Procedures 
 
This policy should be read in conjunction with the Cosmetic Plastic Surgery Procedures 
(APPENDIX J) and the description contained within it of the assessment process for eligibility to 
receive funding for cosmetic plastic surgery. 
 
3.4 Reporting 
 
A process will be put into place to monitor referrals received and decisions made.  The 
Individual Case Review Manager will use the database to produce reports to the Individual 
Case Review Committee to enable a review to be undertaken and to submit reports and/or 
recommendations to the PCT Board as required.  This will include an annual finance/activity 
report. 
 
 
4.  INDIVIDUAL CASE REVIEW COMMITTEE MEETINGS 
 
4.1 
Requests for funding 
 
a) The Individual Case Review Manager will agree agenda items with the Deputy Director of 
Commissioning to include: cases to be considered by the Committee, cases and issues for 
information/noting and feedback from Appeals. 
 
b) The Individual Case Review Manager will circulate to members of the Committee the 
agenda, notes of previous meeting, details of requests including referral letters, decision 
record sheets and any additional information received 1 week prior to the meeting. 
 
c)  Terms of reference for the Individual Case Review Committee are detailed in APPENDIX G.  
 
d) The Individual Case Review Committee will assess and evaluate the evidence base for the 
clinical and cost effectiveness of each intervention and for each patient under discussion 
and will consider the views of all relevant stakeholders based on all the information made 
available to the committee at the time the case is being considered.  The Committee will 
apply the agreed decision-making principles (APPENDIX C) in coming to its decision.  
Primacy of decision-making will be applied to Clinical Effectiveness and Cost Effectiveness. 
 
e) For clinically urgent requests (where a patient’s health may be seriously adversely affected 
if a decision is not taken before the next scheduled meeting of the committee), the 
Committee will delegate authority to the Public Health Consultant/specialist, the Deputy 
Director Commissioning and Performance and the Chair of the Committee or their deputy to 
make decisions.  The Committee will be informed of such cases at the next meeting. 
 
f)  The Individual Case Review Manager will record all decisions on the Decision Record 
proforma, and will produce a response and send to referrer together with details of the 
appeals process in cases where the request is refused. All outcomes will be notified to the 
referrer in writing.  Where appropriate the decision will be copied to the patient’s GP.  
Where appropriate, consistent with NHS Guidance on copying letters to patients, the 
decision will also be copied to the patient. 
 
 
     
 
10 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
g)  The Individual Case Review Manager will then add the Decision Record proforma and copy 
letter to the patient’s case file.  The database will be updated appropriately. 
 
h) The Individual Case Review Manager will produce suitably detailed notes from the 
Individual Case Review Committee meetings, which will detail a record of attendees, case 
numbers discussed and processes and outcomes agreed. 
 
i)  Letters of confirmation will be sent within 3 working days of the date the decision was 
made, will be in a standard format to include information on the appeals process, will 
include a copy of the Decision Record for information and will be addressed from the 
Chairman of the Individual Case Review Committee and signed on the Chair’s behalf by the 
Individual Case Review Manager. 
 
4.2 Reconsiderations 
 
a)  Where significant new or additional evidence is presented that was not available to the 
Individual Case Review Committee at the time of the initial consideration of the case, the 
case will be reconsidered against this evidence by the Individual Case Review Committee. 
 
b)  Requests for reconsiderations will be accepted from the patient’s treating clinician acting on 
behalf of the patient or from the Appeals Panel – usually within 28 days if the letter 
informing the applicant of the decision not to fund the treatment. 
 
c)  All new or additional evidence presented will be assessed and ratified by the Public Health 
Consultant and, where agreed to be significant, will be reconsidered at the next meeting of 
the Individual Case Review Committee. 
 
d)  The Individual Case Review Committee will reconsider a case once only on the grounds of 
new or additional evidence, in line with the process described in this policy. 
 
e)  Where the new or additional evidence is not considered significant, (for example no 
additional evidence of clinical effectiveness is provided and/or the patients clinical 
circumstances have not materially changed) the Individual Case Review Committee will not 
reconsider the case and the decision will be relayed to the referrer, together with details of 
the appeals process. 
 
f)  Where the Appeals Panel has heard a case, and a decision is made to refer the matter 
back to the Individual Case Review Committee for further reconsideration, the case will be 
reconsidered against the recommendations made by the Individual Case Review 
Committee at its next meeting.. 
 
g)  Any decision taken by the Individual Case Review Committee on cases referred for 
reconsideration by the Appeals Panel shall be final and no further appeal shall be allowed. 
 
4.2 Appeals 
 
a)  Where an individual is able to demonstrate that the decision reached by the Individual Case 
Review Committee was unreasonable (for example, not properly based on the evidence set 
before the committee, or not all of the available evidence was taken into account in 
reaching the decision), they have a right to appeal.    
 
b)  The current NHS complaints procedures make it clear that commissioning decisions are not 
part of the ambit of the complaints procedures.  
 
 
     
 
11 

---

S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts 
County tPCT Board\Agenda Papers\2008\May 2008\B08.056 - Policy on the management of 
named patient fundingRevised Policy (2008 version) (3).DOC 
 
 
c) The appeals procedure is convened by a PCT Officer nominated by the Director of 
Commissioning and Performance. The members of the appeal panel must not have had 
any prior involvement or part in the decision making process.   
 
d)  The Terms of Reference and procedures for the operation of the Appeals Panel are set out 
in Appendix H. 
 
 
     
 
12 

---

 
 
 
 
5. SPECIFIC 
ISSUES 
 
5.1 Co-funding 
 
a) Co-funding – the practice of supplementing the cost of private treatment by using NHS 
funding is not supported. 
 
b) Whilst the Department of Health is committed to closer co-operation between the NHS and 
the private and voluntary health care sectors for the benefit of patients this is on the basis of 
developing a wider range of health facilities in the locality. The Concordat between the NHS 
and the Independent Healthcare Association does not relate to individual patient requests 
for treatment in the private sector. 
 
c) Individuals remain free to spend their own money as they see fit, but public funds will be 
devoted solely to NHS patients, and will not be used to subsidise individuals’ privately 
funded healthcare. 
 
 
5.2 Continuation of Private Treatment 
 
a) The PCT will not fund the treatment costs of any self funded private patient who 
subsequently cannot afford further treatment or their private health insurance does not 
cover treatment costs.  
 
b)  Private patients transferring into the NHS will be subject to standard waiting times and 
should be managed by the receiving hospitals as a new referral.  These patients should be 
referred to the beginning of an accepted NHS care pathway as an outpatient referral.   
 
c)  Private patients transferring to NHS care will be treated in accordance with the PCTs 
commissioning policies. If the previously planned treatment is not routinely available in the 
NHS an alternative mode of conventional treatment should be considered. 
 
d)  The PCT will not provide retrospective funding for any treatment initiated privately – even if 
the patient is later successful in a funding request from the PCT.  If funding is agreed for 
any treatment, funding will become the responsibility of the PCT from that date of the 
Individual Case Review Committee meeting at which the request for funding was 
considered. 
 
 
5.3 Second Opinions 
 
a)  Patients are entitled to request a second consultant opinion but this must be within an NHS 
funded clinic. The PCTs Commissioning Team is available to offer advice on preferred 
providers. 
 
b)  In certain cases, the ICRC may request a second opinion from a specialist to assist in 
decision-making and before agreeing a request for funding. 
 
 
5.4 Claims for Expenses 
 
a) Patients are entitled to request assistance with travel costs in order to undertake treatment 
in healthcare facilities commissioned by the PCT.  In most circumstances the healthcare 
facilities themselves will re-imburse travel costs in line with national guidance.  However, in 
certain circumstances (e.g where travel outside of England is required) patients may 
request assistance with travel costs and accommodation costs.  Cases will be considered 
 
     
 
13 

---

 
 
 
 
on a case-by-case basis and will be funded in accordance with national recommendations 
set out in DoH policy. 
 
b) Patients who have donated an organ to a named recipient (living donor) are entitled to 
request reimbursement of reasonable expenses to cover (for example) loss of earnings 
whilst they recuperate.  The PCT will reimburse reasonable expenses – usually in line with 
the value normally recommended by the renal network in which the operation takes place.  
Evidence of earnings will be required before reimbursement can take place. 
 
 
5.5 Access to/Requirement for Psychological Assessment 
 
In certain cases, a psychological assessment will be an expected part of the patient pathway – 
for example, as part of the gender re-assignment pathways. 
 
 
5.6 Exceptionality 
 
Where a treatment is not routinely commissioned, but is requested to be considered under 
exceptional circumstances the definition and criteria for this needs to be clearly established for 
the benefit of the patient, treating clinician and Individual Case review Committee.  APPENDIX 
B, if properly and fully completed, will indicate patient exceptionality. (Exceptional ability to 
benefit.) 
 
Cases will be assessed for exceptionality as follows: 
 
a)  The test applied is one of fairness to fund the treatment for one individual in one specific 
clinical circumstance while declining all others. The focus is on clinical, not social or 
economic, circumstances. The clinical circumstance must be directly related to the 
requested treatment for the particular patient. 
 
b)  Patients who have received privately funded treatment will not qualify as 'exceptional' on 
the basis of their response to treatment. 
 
 
5.7 Support for decision-making 
 
a)  Some decisions are particularly difficult to make. Reasons for this include: 
 
•  There is potential to set a significant precedent 
•  Significant uncertainty regarding the case 
•  Difficult ethical issues 
 
b). An expert group may be asked to be convened by the Individual Case Review Committee 
to advise on a case/decision. The advice of such a group is not binding on the PCT. 
However, the advice should be made available if there is an appeal made against the 
PCT’s decision. 
 
c)  Where the Individual Case Review Committee considers it necessary to develop interim 
commissioning policies, the Public Health lead will produce relevant guidelines for 
consideration by the Committee. 
 
d)  For some treatments or drugs, the PCT may consider there are no circumstances under 
which they treatments or drugs would be funded (eg where an identical drug exists at a 
lower cost). The PCT has been advised that 'Blanket bans' of this type are legally 
permissible. 
 
 
     
 
14 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX A – SCHEDULE OF LOW PRIORITY TREATMENTS 
Revised May 2008 
 
INTERVENTION 
LOW PRIORITY SITUATION 
 
Gastroplasty 
For patients meeting the East Midlands Obesity Pathway Criteria, Dietary and 
pharmacological interventions should already have been undertaken and failed. 
Surgery for correction of short sight 
Not funded 
Autologous Cartilage 
Not funded as routine treatment.  All other treatment regimes must have been 
(chondrocyte)Transplantation 
exhausted 
Surgery to address varicose veins 
Asymptomatic – not funded. (Where there is no pain or discomfort, or any skin 
changes) 
Moderate – not funded.  (e.g ankle swelling, feelings of heaviness, swelling, 
generally only involving superficial veins) 
Severe – funded where: ulcers/history of ulcers, liposclerosis, varicose eczema, 
history of phlebitis, history of haemorrhage ot significant pain exists. 
Hyperbaric oxygen therapy for wound healing 
Not funded 
Dental Implants 
Not funded except post cancer reconstruction, major trauma with bone loss 
anodontia.  Criteria apply 
Asymptomatic wisdom tooth removal 
Not funded 
Prostheses from independent providers 
The PCT will not fund prostheses from independent providers as these are 
available on the NHS 
Access to independent providers 
Retired NHS clinicians may continue to practice privately.  The PCT will not fund 
patients who wish to continue to see a private consultant where an NHS 
alternative exists. 
Circumcision 
Not normally funded in either adults or children unless there are medical 
indications. 
Gender reassignment 
Counseling and psychological support funded.  Drug therapy and surgery not 
normally funded 
Reversal of male sterilisation 
Not funded 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - APPENDIX A (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX A – SCHEDULE OF LOW PRIORITY TREATMENTS 
Revised May 2008 
INTERVENTION 
LOW PRIORITY SITUATION 
 
Reversal of female sterilization 
Not funded 
IVF/ICSI/IUI and other forms of assisted 
Criteria apply.  Refer to PCT policy on Assisted Conception 
conception 
Penile Implants 
Not funded except in patients with impotence of organic cause, or for those who 
have failed to respond to, or are unable to continue with, medical treatment or 
external devices 
Spinal Cord Stimulation for Chronic Pain 
Not funded 
 
Pain management programmes using 
Not funded 
cognitive behavioural approach 
Residential pain management programmes 
Not funded 
Acupuncture for pain relief 
Funded only where recommended by consultant in pain clinic. 
Therapeutic community method for treatment 
Not funded 
for borderline personality disorder 
Out of area treatment for chronic Fatigue 
Not funded.  Local pathway in place.  Community-based model with access to in-
Syndrome/ME 
patient care in Derby in severe cases. 
Post Traumatic Stress Disorder 
Not funded unless referral made by consultant psychiatrist in local Services.  Prior 
Approval required. 
Out of Area or referrals to the independent 
Referrals to the independent sector or out of area will only be considered where 
sector for Children with suspected Autism 
the child’s care has been assessed by CAMHS or paediatric services and where 
there is a recommendation by either or both agencies that such a referral is 
necessary. 
Acupuncture for purposes other than pain 
Not funded 
relief, including smoking cessation 
Osteopathy and chiropractic 
Not funded unless an agreed care pathway is already in place. 
Glucosamine Not funded
 
 
Herbal remedies 
Not funded 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - APPENDIX A (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX A – SCHEDULE OF LOW PRIORITY TREATMENTS 
Revised May 2008 
INTERVENTION 
LOW PRIORITY SITUATION 
 
Homeopathy 
Not funded 
Chinese medicines 
Not funded 
Aromatherapy 
Not funded although sometimes offered in hospices and other palliative care 
settings 
Massage No  
t funde  
d
Reflexology No  
t funde  
d
Hypnotherapy No  
t funde  
d
All other complementary therapies 
Not funded 
 
(Interventions listed in lighter – blue – text indicate a change from the previous (2007) version of the policy.  In some cases, these 
are new additions to what the PCT considers to be low priority in other cases this (2008) version provides greater clarity. 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - APPENDIX A (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
PCT Ref
Named Patient Funding Request 
Please use this form in the following circumstances to apply for resources from 
Nottinghamshire County teaching Primary Care Trust (NCTPCT) for an individual patient 
where the PCT does not routinely fund the treatment. 
Either there is an expectation that your patient has an exceptional ability to benefit above 
that of other similar patients (we suggest that you read the attached guidance notes) 
Or the patient has a rare condition for which the PCT does not have a formal policy. 
The nature of the information required to best support an application is usually most 
thoroughly completed by the specialist who decides the requested intervention may be 
appropriate. 
The form should not be used where the proposed intervention would logically apply to a 
group of patients without a rare condition. In these circumstances a business case for a 
service development should be submitted to the PCT using the normal process, through your 
Trust’s commissioning liaison.  
Please request an electronic version of this form through your commissioning liaison team. 
The form will be easier to complete, as boxes will expand to fit your submission. We will start 
the process on receipt of an electronic copy, but a paper copy should be submitted through 
your commissioning liaison team complete with the necessary signatures. 
Section A 
Governance, Patient, Clinician & Trust details 
A1 Trust governance confirmation 
The request will be returned unless the governance requirements below are confirmed 
Fully informed consent 
date patient 
for the proposed 
 
consented 
intervention 
Conflict of Interest/Bias 
date  
statement completed 
Provider DTC/Ethics 
date to 
 
yes / no 
 
approval 
DTC/Ethics 
Provider Clinical 
date  
Director support 
(signature of clinical director)
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
A2 Patient details 
Surname  
Forename 
 
DoB  
Sex 
 
NHS Number 
 
Hospital ID 
 
Address  
Registered GP 
 
Diagnosis  
Intervention  
Additional costs 
 
Exceptionality 
Is request on grounds of  Exceptionality  ?     
One off Decisions 
Is request on grounds of one off decision ? 
There may be no reference point, the patient does not come from a sizeable group of 
patients (often they may be unique), nor is there much evidence about the treatment in 
question   
What is the nature of the condition ?   
 
What is the nature of the treatment?   
 
What is the evidence that this treatment might work in this situation?  Is there biological 
plausibility that this treatment might work?                                                                                  
 
 
A3 Requesting clinician details 
Surname and title 
 
Forename 
 
Specialty  
Trust 
Name 
 
Address  
Telephone  
Fax 
 
 
A4 Proposed provider details 
Complete if different to requesting clinician 
Surname  
Forename 
 
Specialty  
Trust 
Name 
 
Address  
Telephone  
Fax 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
A5 Provider commissioning liaison details 
When from a Trust, the request should be forwarded through your commissioning liaison 
Surname  
Forename 
 
Telephone  
Fax 
 
Date forwarded to PCT   
Trust reference 
 
 
A6 Tracking 
This section is for PCT use 
PCT Reference 
 
date received   
Is this patient the responsibility of this PCT (if registration changes so does responsibility) 
Registered at PCT GP 
 
y / n 
PCT commissioning liaison assessment of completeness 
name(s)  
date(s) 
 
Returned to Trust commissioning liaison if unacceptably incomplete 
date(s)  
Commissioning or Pubic Health assessment that case made is one of exceptionality or rarity
(Director of Commissioning or Public Health, Associate Director of commissioning or Consultant in Public Health)
name(s)  
date(s) 
 
Returned to Trust if request not made on the basis of exceptionality or rarity 
date(s)  
Withdrawn or not progressed by Trust 
date  
Recheck registered GP  (if registration changes so does responsibility) 
Registered at PCT GP 
 
y / n 
Have there been any similar requests to the PCT in the past, and what was the outcome. 
 
Forwarded to Individual Case Review Committee 
date  
date 
 
Considered by Individual Case Review Committee 
decision  
panel 
date 
 
Grounds for decision 
Legality 
y / n 
Safety  
y / n 
Effective  
y / n 
Cost Effective    y / n 
Equitable  
y / n 
Accessible  
y / n 
Affordable  
y / n 
Exceptional     y / n 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
Section B 
PCT Decision-Making Principles 
The PCT has a set of Decision-Making Principles, which it uses to help prioritise the 
distribution of health care resources. Each of the main points of the policy are addressed in 
the boxes below 
If you are making an application on the grounds of “exceptionality”, we would suggest that 
you read the attached guidance notes so that you aware what we mean by “exceptionality” 
before continuing. The majority of applications for Named Patient Treatment Request on the 
grounds of “exceptionality” we have received in the past have not met the requirements of 
“exceptionality” and have most often been refused on the grounds that they have essentially 
been requests for service development because the request would actually have applied to a 
group of patients. 
Similarly, the PCT does not divert resources from other patients solely on the basis of the 
“rule of rescue”. 
B1 Legality 
1a. Do you consider the treatment you are recommending to be lawful and comply with 
human rights act 
yes / no 
 
B2 Safety 
Standard management options should have been exhausted for this patient 
1a. What interventions/management options have already been tried? 
 
1b. What was their outcome 
 
1c. Are there other further interventions available that you or others would normally use 
which are already funded by the PCT, but have not yet been tried? 
 
1d. If “yes” to 1c, why have these not be tried? 
 
Those proposing to undertake the intervention should be suitably skilled 
2a. What evidence is there that the clinician who is to undertake the intervention is 
appropriately trained and accredited (where and by who)? 
 
2b. What is the experience in the unit of this intervention? 
 
2c. Are there known activity levels that affect positive outcomes and what are these? 
 
2d. If yes to 2c, how do these compare with the activity in the proposed unit 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
B3 Clinical Effectiveness 
The status of the proposed intervention should be clear 
1a. If a drug, is it licensed for the proposed use? If an intervention is it usually recommended 
(and by who)? 
 
1b. Is the intervention still the subject of clinical trials? Please give details. 
 
1c. If resources are made available for this intervention, what ongoing audit programme will 
outcomes be fed into? 
 
A summary of the evidence base about the intervention should be included. Any 
assessments by advisory bodies or research papers should accompany the application 
(preferably electronically). As the requesting clinician it is important to realise that the 
application may be subject to bias. It is therefore important to fully complete the 
sections below on evidence. Obvious bias detracts from the strength of an 
application. Please highlight systematic review, meta-analyses and RCTs 
2a. What evidence is there to support the use of this intervention in this patient? 
 
2b. What evidence is there that does not support the use of this intervention in this patient? 
 
2c. What gaps are there in evidence for the use of this intervention in this patient? 
 
2d. How generisable to this patient is the evidence you have highlighted? 
 
The proposed intervention should have a high likelihood of producing a demonstrable 
significant functional improvement, or substantially reduce the risk associated with the 
standard intervention. 
3a. How is it anticipated that the intervention will impact on the patient’s functional abilities 
with, for example, activities of daily living? 
 
3b. What and by how much will risks associated with standard treatment be reduced, and 
risks associated with the intervention be increased?  
 
3c. Has the information that you have provided above on the evidence and the associated 
uncertainties for this intervention been discussed with your patient during the process of 
obtaining informed consent? 
 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
B4 Cost Effectiveness 
It is the PCT’s responsibility to establish the cost-effectiveness of the intervention for the 
individual when weighed against alternative management options and against its 
responsibility to ensure improved health for all those in the population for which it is 
responsible. Information on the following will help with the decision on this application 
The funding requirements should be explicit and clear, and should include medium to long 
term follow-up and other likely future costs of the pathway. 
1a. What is the cost of delivering this intervention? 
Drug/Procedure -  
Hospital activity -  
1b. What are the future costs associated with this care pathway? 
Drug/Procedure -  
Hospital activity -  
1c. What costs will not need to be met as a result of not using a standard intervention? 
Drug/Procedure -  
Hospital activity -  
Intervention aims, monitoring and stopping criteria 
2a. Have clear outcomes (goals of functionally significant change) been set with the patient? 
 
2b. What level of response will be considered ineffective 
 
2c. How is the response to the intervention to be monitored 
 
2d. What is the end point at which the intervention should stop and does your patient 
understand this and realise that the intervention will then stop? 
 
2e. What are the longer term follow up arrangement and who is responsible for ensuring that 
follow up takes place? 
 
2f. Are additional resources required for follow up? 
 
National/Independent assessments of cost effectiveness 
3a. Has there been a NIHCE assessment of this intervention? If so what was the outcome 
and what is the NIHCE reference? You should not leave this blank State none if none 
 
3b. Has there been a SMC assessment of this intervention? If so what was the outcome and 
what is the SMC reference? You should not leave this blank State none if none 
 
3c. If a drug, has there been a DTB, MeReC, NPC or similar review? If so what was the 
outcome and what is the reference? You should not leave this blank State none if none 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
B5 Equity & Exceptionality 
The PCT must ensure that all its patients with similar need are treated in the same way 
irrespective of clinical picture, social or personal circumstances (unless these should have a 
direct bearing on clinical outcomes).  
1a. How is this patient different to the general patient population with this problem? (if you 
are applying on the grounds of exceptionality, you will need to identify real and significant 
differences. Social criteria and presumed previous response do not support an argument of 
exceptionality – please see attached guidance) 
 
1b. Are you recommending that patients in a similar position have this intervention (this 
question will rarely apply if the application is on the basis of exceptionality because if there is 
a group of patients in a similar position an individual patient cannot be an exception) 
 
1c. If your application is based on rarity and the absence of a PCT policy, please indicate the 
incidence and prevalence of this condition in the general population. (guidelines for our 
decision are 3 per million per year incidence, and 10 per million prevalence) 
 
 
B6 Accessibility 
The PCT has to ensure that patient choice, including care as close to the patient’s home as 
is feasible, is available where possible. 
1a Have the patient been made aware of alternative providers of this intervention? 
 
1b Are there providers of this intervention closer to the patient’s home? 
 
 
B7 Affordability 
Applicants should note that Nottinghamshire County teaching PCT will make all its 
commissioning decisions in the light of the totality of resources available to it. The PCT has a 
statutory duty to balance its budget. 
 
 
Abbreviations 
PCT Primary 
Care 
Trust 
DTC 
Drugs and Therapeutic Committee 
NIHCE 
National Institute of Health and Clinical Excellence 
SCM 
Scottish Medicines Consortium 
DTB 
Drugs and Therapeutic Bulletin 
NPC 
National Prescribing Centre 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
C1 Conflict of Interest 
Clinicians may have a variety of interests that arise out of the course of their work or from their 
personal life that may conflict, or be perceived to conflict, with the advice they give when 
recommending a particular intervention or policy. The following questions are derived from the NIHCE 
code of practice on conflicts of interest. Please refer to this at 
http://www.nice.org.uk/niceMedia/pdf/Declarationofinterestpolicy.pdf for a complete description. The 
application will be returned if this declaration is not completed. 
Relevant interests are from the last 12 months, or planned for the coming 12 months  
A personal pecuniary interest 
A regular payment in cash or in kind, fee paid-work, shareholdings, expenses and hospitality above 
which you would have had if you had been self financing, from a consultancy, directorship or position 
in or work for the manufacturer or owner of the product or intervention being recommended (specific 
interest) or the industry or sector from which the product or intervention comes (non-specific interest) 
 Yes or no    
If yes, specific or non specific    
 Details 
 
A non personal pecuniary interest 
A payment or other benefit to a department or organisation for which an individual has managerial 
responsibility that is not received personally. This includes fellowships or grants from a company to 
run a unit, support staff or commission research. This may relate to the intervention in question 
(specific interest) or to the manufacture or owner of the intervention but not to the intervention itself 
(non-specific interest) 
 Yes or no    
If yes, specific or non specific    
 Details 
 
A personal non pecuniary interest 
This may include, but is not limited to, a clear opinion of the conclusion of research or clinical/cost 
effectiveness evaluation of a recommended intervention, a public statement where a clear opinion has 
been expressed that may be interpreted as prejudicial to objective interpretation of evidence, holding 
office in a profession organisation or advocacy group with an interests in the intervention, or other 
reputational risk that relates to the intervention 
 Yes or no    
If yes, then by definition it is specific 
 Details 
 
A personal family interest 
For a family member, a regular payment in cash or in kind, fee paid-work, shareholdings, expenses 
and hospitality above which they would have had if they had been self financing, from a consultancy, 
directorship or position in or work for the manufacturer or owner of the product or intervention being 
recommended (specific interest) or the industry or sector from which the product or intervention comes 
(non-specific interest) 
 Yes or no    
If yes, specific or non specific    
 Details 
 
Declaration: I have indicated all my potential conflicts of interest 
Signature 
date  
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
Individual Case Review Committee 
Guidance notes and clarification of process 
General  
1.  PCT policy already states that medicines and interventions that fall outside existing 
contracts, tariffs or NICE consideration are not normally supported if they require 
significant additional resources with attached opportunity costs. Within the fixed budget 
the PCT is provided with, a choice to fund one patient’s treatment is also a choice not to 
fund one or more other patient’s treatment. It is a role of the PCT to decide, with 
consultation, which interventions for which groups of patients are prioritised. 
2.  Hence, all funding requests for an individual patient to have a treatment that the PCT 
would not normally provide as a matter of policy must be on the basis of exceptional 
circumstances. The Individual Case Review Committee (ICRC) is a sub-committee of the 
PCT board, and will make the decision on whether there is exceptionality and whether 
the request will be funded. 
3.  The presence of permission based on licence, Drugs and Therapeutics Committee 
approval, or previous receipt of the intervention, as part of a trial or privately (whatever 
the presumed response), is insufficient alone to support an application.  
Appeals  
4.  The PCT ICRC appeals process is only to appeal against the ICRC process itself and 
not the decision. This is in common with Specialised Commissioning Guidance and 
practice in other ICRCs. Where an appeal is upheld, the ICRC will be asked to repeat 
their assessment taking into account the appeal panels comments on process. Having 
done so, the decision reached by the ICRC may not change. If significant additional 
information to support an application becomes available where there has been a 
previous decision not to fund, then a new application can be made, and an appeal 
against the ICRC process is unnecessary. If new information is offered, but its 
significance is uncertain, the original panel may consider it.   
Exceptions  
5.  Exceptionality refers to an individual’s exceptional ability to clinically benefit compared 
with others in a similar position. It does not refer to patients social factors1. 
6.  Exceptions are by definition difficult to define. If sub-groups of patients can be shown 
from robust evidence and by the nature of certain characteristics to benefit more than 
others from a particular intervention, then they form a good prognosis group and are not 
exceptions.  Patients in those good prognosis groups may then be considered for 
funding via the usual LOP process, and the evidence base to support this is likely to be 
more favorable than for all patients with the same condition. Many NICE decisions 
already work on this basis. Therefore, if the basis of an application for an individual 
would in fact apply to a group of patients, there can be no exceptionality, and a business 
case should be submitted through the normal prioritisation process. 
                                            
1 Social factors include work status, marital status, dependants  
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
7.  Patients who present who are clearly individuals who show characteristics of potential 
exceptional prognosis or response based on good evidence but where no clear evidence 
that other similar patients exist to justify or anticipate a ‘good prognosis group’ demand, 
as in 6 above, may be considered exceptions.   
8.  If the evidence for particular benefit is present but not strong enough to follow the 
process outlined in 6 above (eg if it is inferred, observational, not from ‘a priori’ research, 
or based on clinical opinion), then such patients, especially if this situation is rare, may 
be considered exceptions. However, some evidence must be available. An example of 
the dilemma panels may face is that there may be a clinical argument advanced that a 
patient is younger and free of co-morbidity and so may promise exceptional survival for a 
given contested cancer treatment intervention. This would normally have to be backed 
up with some evidence since some tumours in younger patients may behave more 
aggressively and the evidence base may not include patients in certain groups. 
Clinicians should support their advice with evidence and panels are expected to judge 
the individual arguments.  
Principles of decision-making 
9.  Blanket bans on potentially effective interventions ‘fetter discretion’ and so are difficult to 
justify. All uncertain cases should be progressed via ICRCs.   
10.  Where the ICRC decides that there is exceptionality, then the existing principles set out 
in the PCT’s Policy on the management of Named Patient Funding Requests will be 
applied before funding is agreed. These do not currently include the ‘rule-of-rescue’.  
11.  Only clinical benefit for a given demographic profile can be considered as parameters of 
exceptionality. Social factors2 must not be used in the consideration. 
Evidence 
12.  Clinicians applying on behalf of their patients should be open about the level of evidence 
available to support their request. They should give not just the evidence for the 
intervention, but also indicate the evidence against it, and where there are gaps in 
evidence. The presence of obvious bias in the evidence presented detracts from the 
strength of an application. 
13.  Most if not all evidence used by the panels will be based on randomized controlled trials. 
Occasionally high-quality observational data may be appropriate. Good prognosis sub-
groups exist in the non-treatment or placebo arm as well as the treatment arms and so 
the presence of a ‘good prognosis sub-group’ has to be judged in comparison with its 
randomized comparator NOT the overall performance of the whole intervention cohort. 
14. It is often proposed that patients who might represent exceptions are started on 
treatment ‘to see how they respond’, with subsequent funding decisions being based on 
a report submitted by the clinician at some stage in the future. It is advised that this is 
not a robust or sound process since many patients in clinical trials may be considered to 
‘respond’, but it is ultimately primary endpoints on which the whole basis of the evidence 
is predicated, and so treatment decisions should be determined a priori and on an 
intention-to-treat basis in all cases considered by the panel, whatever the subsequent 
‘on-the-ground’ clinical management that ensues. 
                                            
2 Social factors include work status, marital status, dependants 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX B – REQUEST FOR NAMED PATIENT FUNDING 
Revised May 2008 
 
Other 
15.  Applications can be initiated from a patient themselves, or anyone on behalf of a patient. 
The nature of exceptionality and the necessary collation and assessment of evidence to 
support an application mean that the vast majority of applications will be from a patient’s 
clinician. If an application is made by anyone else, we will always request their clinician’s 
involvement, including their assessment of exceptionality and the evidence base. 
16. Clinicians may disagree with the PCT’s existing policy not to fund a particular 
intervention. The usual Local Operational Plan prioritisation process is the appropriate 
route to submit proposals for new policies. The ICRC should not be used as a 
mechanism for this. 
17. Given the nature of exceptionality, an individual decision to fund treatment is very 
unlikely to form a precedent either for future decisions of the ICRC or for the PCT 
policies. 
     
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 Appendix B (2).doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX C– Individual Requests for funding – Decision Making Principles 
Revised May 2008 
 
 
Individual requests for funding 
Decision-Making Principles 
 
1 
Legality (is it lawful?) 
 
 Nottinghamshire County tPCT will ensure that any decision it takes on the commissioning of new 
services and treatments is within its legal powers and complies with the principles of the Human 
Rights Act (which do not impose on the PCT a duty to provide health care). 
 
 
2 
Safety (‘first do no harm’) 
 
Nottinghamshire County tPCT will ensure it is not complicit in exposing patients to unsafe 
healthcare and will look to licensing authorities (especially the MHRA) and other organisations 
(such as NICE and the BNF) for guidance. 
 
 
3 
Clinical Effectiveness (does it work?) 
 
Nottinghamshire County tPCT will only commission new services and treatments which are fully 
accredited and approved and where there is good evidence that a specific benefit will be gained. 
 
 
4 
Cost Effectiveness (is it an efficient way of using resources?) 
 
Nottinghamshire County tPCT will aim to commission services and treatments, which yield the 
greatest benefits relative to the cost of providing them. This balances the clinical effectiveness of a 
service or treatment with its cost. Interventions are not always completely effective all the time and 
the benefit to the individual needs to be balanced with the greater good. 
 
 
5 
Equity – Including Equality and Diversity (is it a fair way of using resources?) 
 
Nottinghamshire County tPCT will endeavour to ensure that a service or treatment is available to all 
those who could benefit from it, taking into account the requirement to balance the needs of the 
individual and those of the local community 
 
 
6 
Accessibility (can people get to the service?) 
 
Nottinghamshire County tPCT will, whenever possible and appropriate, commission services and 
treatments that are accessible to all the people it serves. 
 
 
7 
Affordability (do we have the resources to pay for it?) 
 
Nottinghamshire County tPCT will make all its commissioning decisions in the light of the totality of 
resources available to it. 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - Appendix C.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX D– Schedule of future meetings and Standard response times 
Revised May 2008 
 
 
Individual Case Review Committee 
Schedule of future meetings and Standard response times
 
SCHEDULE OF FUTURE MEETINGS 
 
12 June 2008 
10 July 2008 
14 August 2008 
11 September 2008 
9 October 2008 
13 November 2008 
11 December 2008 
8 January 2009 
12 February 2009 
12 March 2009 
9 April 2009 
 
 
STANDARD RESPONSE TIMES FOR CONSIDERATION BY INDIVIDUAL CASE REVIEW 
COMMITTEE 
 
Referral received by commissioning directorate 
(Day 0) 
Referral acknowledged within 3 working days.  
Referrer advised how the request is to proceed 
(if covered by contract, NICE guidance in place, 
PCT criteria in place, will progress to ICRC case 
or declined/not fundable.)  Referrer advised 
whether additional information will be required. 
If referral is urgent in nature, convene urgent 
decisions process and advise referrer of the 
outcome within 5 working days 
Maximum waiting time for case to be considered 
by ICRC is 30 Calendar days.  (Assuming worst 
case scenario of case being received 
immediately following a meeting and case 
needing to be considered by next committee.)  
Please note that the case cannot proceed 
without full information required for decision-
making.  In rare circumstances, the volume of 
cases may necessitate cases being deferred 
until next available committee meeting. 
 
Clinically urgent cases will take priority. 
Following Committee meeting, referrer and 
patient advised of outcome within 3 working 
days 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - Appendix D.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX D– Schedule of future meetings and Standard response times 
Revised May 2008 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - Appendix D.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX E – Process flowchart for assessing Named Patient Funding Requests 
Revised May 2008 
 
 
 
 
Request Received 
 
and logged 
 
 
 
Details obtained by Individual 
 
Case Review Manager 
 
 
 
Initial screen by Individual Case Review Manager to determine whether 
 
a decision can be made by reference to NICE and/or other mandatory 
guidance or whether the area of care is covered by/excluded from a 
 
Develop policy 
current service agreement/contract 
 
or service 
 
agreement(s) 
 
as necessary 
 
No 
Yes
 
 
Manage Request for 
 
Is there a 
funding outside 
 
Policy? 
ICRC
 
 
 
Yes 
No 
 
 
 
Evidence base requested if needed 
Apply Policy     
 
and 
 
Judge if justified to meet need 
Monitor 
 
Public Health liaison and advice
 
 
 
 
Is there any doubt about clinical 
 
benefit or service/treatment 
 
proposed? 
 
 
 
 
Yes 
No
 
Regular monitoring and 
 review of requests as 
 
Consider: 
required 
Agree referral but 
Likely benefit to patient 
 
Risks of NOT agreeing 
emphasise that no 
 
Alternatives 
precedent has been 
 
Decision-making principles 
set 
Previous cases/examples 
 
 
Individual Case Review Committee 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - Appendix E.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX E – Process flowchart for assessing Named Patient Funding Requests 
Revised May 2008 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - Appendix E.doc 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
 
 
 
 
 
 
Assisted Conception Policy 
 
 
 
 
NHS Eligibility Criteria for In vitro fertilisation (IVF) 
Intracytoplasmic sperm injection (ICSI) and Intra-
uterine insemination (IUI) treatment for people with 
infertility in Nottinghamshire County. 
 
May 2008 
1
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
Summary 
 
Couples referred for investigation and diagnosis will be eligible for one cycle of NHS 
funded In vitro fertilisation (IVF) or Intracytoplasmic sperm injection (ICSI) if they 
meet all of the following criteria (NICE indicates that the criterion is based on NICE 
guidance): 
 
1.  couples who have failed to conceive after regular unprotected sexual intercourse 
for 3 years; or who have an established cause of infertility.  Investigations will 
begin at 2 years or earlier if there is a history of predisposing factors (NICE). 
 
2.  female partner to be aged 23-39 at the start of the treatment cycle (NICE) 
 
3.  neither partner has been previously sterilised 
 
4.  female partner to have a BMI between 20-29 (NICE) 
 
5.  both partners to be childless 
 
6.  no more than 2 cycles of IVF already received (regardless of NHS or privately 
funded) - couples are only eligible to receive up to a maximum of 3 cycles in a 
lifetime regardless of NHS or privately funded (NICE advise up to 3 cycles for 
eligible couples) 
 
7.  the couple’s health and/or social circumstances would pose no significant risk to 
conception, pregnancy or the resultant child 
 
8.  the couple are to be registered with a Nottinghamshire County GP 
 
9.  written consent to treatment is required from both partners 
2
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
Introduction 
 
This paper sets out the criteria for access to NHS funded specialist fertility services 
for patients who are the responsibility of the Nottinghamshire County Teaching PCT. 
 
It sets out the minimum entitlement and service that will be provided for NHS In vitro 
fertilisation (IVF) Intracytoplasmic sperm injection (ICSI) and Intra-uterine 
insemination (IUI) across the health community. 
 
Initial investigation of patients, to be started after two years of infertility (NICE) is 
usually carried out by a network of specialist gynaecologists at District General 
Hospitals throughout the Nottinghamshire area. 
 
In any healthcare system there are limits set on what NHS funded care is available 
and on what people can expect.  Primary Care Trusts (PCTs) are required to achieve 
financial balance; they have a complex task in balancing this with an individual’s 
rights to health care.  It is the purpose of the criteria set out here to make the limits 
on fertility treatment fair, clear and explicit. 
 
Nationally this is undertaken through the work of the National Institute for Clinical 
Excellence (NICE) and this paper reflects this. The paper should be read in 
conjunction with the NICE Fertility Guidance available on their web site at 
www.nice.org.uk-pdf-CG011niceguideline.pdf.url . 
 
The NICE Guidance places NHS assisted fertility services firmly in the mainstream of 
NHS provision, and therefore as a result, patients will expect the NHS to provide this.   
 
Abbreviations used in the document are explained in Appendix A. 
 
Definitions of technical terms are contained in Appendix B. 
 
Appendix C contains some explanatory notes and guidance. 
 
Appendix D is the sub fertility funding assessment sheet.  A completed version is 
required for NHS funding to be considered. 
3
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
Eligibility Criteria 
1 
Availability of In vitro fertilisation (IVF), Intracytoplasmic sperm 
injection (ICSI) 
 
Couples suffering from infertility will be eligible for IVF and ICSI.  Infertility is the 
failure to conceive after regular unprotected sexual intercourse for 3 years.  Where 
there is clear reproductive pathology, couples with infertility of any duration will be 
considered.  This may include couples who cannot achieve full sexual intercourse 
due to disability. 
 
Any element of surrogacy related infertility treatment would not be eligible for NHS 
funding. 
 
Any cycle of infertility treatment already undertaken (whether self or NHS funded) will 
be taken into account when determining NHS funding entitlement. 
 
Since 1st April 2005 all women aged between 23 and 39 who met the eligibility criteria 
have been offered one full cycle of IVF.  This has included ovarian stimulation, egg 
recovery, IVF and embryo transfer.  (It has not included further transfers of frozen 
embryos where the initial procedure did not result in a viable pregnancy.) 
 
Couples who have an appropriately diagnosed cause of infertility of any duration, or 
unexplained infertility (unexplained infertility includes mild endometriosis and mild 
semen abnormality) of at least three years duration, and who meet the other criteria 
should be offered one complete full cycle (that is ovarian stimulation, egg recovery, 
IVF and embryo transfer). 
 
NICE has limited a couple’s lifetime access to IVF to a maximum of 3 cycles. A 
couple who has already had 3 cycles, be they NHS or privately funded (in the UK or 
abroad) will not be eligible for NHS funding. 
 
2 Existing 
Children 
 
Only couples with no children who fulfil all other criteria will be eligible.  
 
(The definition of childlessness is based solely on parental status, in that it requires 
neither partner to have any living children.  A living child is defined as living offspring 
regardless of age, which includes adopted children, or children who may have been 
taken into care, but not foster children.) 
 
3 Female 
age 
 
Assisted reproductive technology will be available to women aged 23 to 39 years at 
the start of a treatment cycle.  A treatment cycle begins with the administration of 
drugs for IVF, IUI and hormone replacement treatment. 
 
Treatment should be started no later than 12 months from the decision to offer 
assisted conception.  Once treatment is started a women will be entitled to one full 
cycle, however treatment will cease by the woman’s 40th birthday.  
 
 
4
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
 
4 
Availability of Intrauterine Insemination (IUI) 
 
Couples who fail to conceive after 2 years unprotected sexual intercourse and fulfill 
the eligibility criteria for IVF may be offered intrauterine insemination if clinically 
appropriate  
 
Couples will normally be offered no more than a maximum of 6 IUI treatments. 
 
Couples who do not conceive after IUI will have a full entitlement to IVF in line with 
the stated eligibility criteria. 
 
Couples of who choose not to have IUI and progress straight to IVF, will not be 
permitted to be offered IUI if IVF fails. 
 
5 Obesity 
 
Women with a body mass index of more than 29 before starting a course of IVF ICSI 
or IUI will not be eligible. 
 
6 Low 
Weight 
 
Women with a body mass index of 19 or under before starting a course of IVF ICSI or 
IUI will not be eligible1. 
 
7 Donor 
Sperm 
 
This will be funded only where the male has azoospermia or severe oligospermia or 
to avoid transmission of inherited disorders to a child where the couple meet the 
other eligibility criteria. 
 
This would mean up to 6 cycles of donor insemination, in addition to IUI if required, 
and in addition to IVF entitlement if required.  
 
8 Donor 
Egg 
 
This will be available to women who have undergone premature ovarian failure due 
to an identifiable pathological or iatrogenic cause before the age of 40 or to avoid 
transmission of inherited disorders to a child where the couple meet the other 
eligibility criteria. 
 
9 Surrogacy 
 
Surrogacy, or any assisted conceptions involving surrogacy, are not funded and do 
not form part of this policy. 
 
 
 
 
                                                 
1 Van der Spuy, Z. M., Steer, P.J., McKusker, M., et al. (1988) Outcome of pregnancy in 
underweight women after spontaneous and induced ovulation.  BMJ 296, 962-967. 
5
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
 
 
10 
Embryo, Ovarian or Testicular Tissue, Egg and Sperm Storage 
 
Embryo storage will not be funded by the NHS. Ovarian or testicular tissue storage 
will not be carried out outside a clinical trial.  These are currently experimental. 
Sperm will be stored according to HFEA Guidance.  This includes freezing of sperm 
for patients undergoing chemotherapy and radiotherapy.  Patients whose sperm has 
been frozen prior to chemotherapy or radiotherapy will be entitled to NHS funded 
infertility treatment provided they meet the eligibility criteria. 
 
11 Sterilisation 
 
Couples where one partner has been sterilised will not be eligible for treatment, even 
if a successful reversal has been achieved (reversals are not funded by the NHS). 
 
12 Exceptional 
circumstances 
 
In the rare or exceptional circumstances where a couple or clinician feel that the 
couple represent a special case then an application can be made to the PCT’s 
Individual Case Review Committee for consideration of exceptional funding. 
 
13 Review 
 
 
These treatment criteria will be reviewed in July 2008 or in the light of any new 
guidance, whichever is the earliest. 
 
 
September 2007 
6
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
Appendix A 
 
Abbreviations used 
 
 
BMI 
Body Mass Index 
DI Donor 
Insemination 
GP General 
Practitioner 
HFEA 
Human Fertilisation and Embryology 
Authority 
ICSI 
Intracytoplasmic sperm injection 
IUI Intra-uterine 
insemination 
IVF 
In vitro fertilisation 
NICE 
National Institute of Clinical Excellence 
PCT 
Primary Care Trust 
 
 
7
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
Appendix B 
Definitions 
  
Term 
Definition Further 
information 
 
BMI 
The healthy weight range is based  BBC Healthy Living 
on a measurement known as the  http://www.bbc.co.uk 
  
Body Mass Index (BMI). This can    
be determined if you know your  NHS Direct 
weight and your height.  This http://www.nhsdirect.nhs.uk 
calculated as your weight in   
kilograms divided by the square of 
your height in metres. In England, 
people with a body mass index 
between 25 and 30 are categorised 
as overweight, and those with an 
index above 30 are categorised as 
obese.   
 
ICSI 
Intra Cytoplasmic Sperm Injection  Glossary, HFEA 
(ICSI): In conjunction with IVF, 
http://www.hfea.gov.uk 
  
where a single sperm is directly 
injected, by a recognised 
practitioner, into the egg.  A clinic 
may also use donor sperm or eggs. 
 
IUI 
Intra Uterine Insemination (IUI): 
As above 
Insemination of sperm into the 
uterus of a woman. 
 
IVF 
In Vitro Fertilisation (IVF): Patient's  As above 
eggs and her partner's sperm are 
collected and mixed together in a 
laboratory to achieve fertilisation 
outside the body.  The embryos 
produced may then be transferred 
into the female patient.  
 
DI 
Donor Insemination (DI): The 
As above 
introduction of donor sperm into the 
vagina, the cervix or womb itself. 
 
  
 
8
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
Appendix C 
 
Explanatory Notes and Guidance 
 
1 Same-sex 
couples 
and single people: 
 
The NICE Clinical Guidance does not cover same-sex couples and single people. 
Infertility for the purposes of investigation at 2 years is judged against a 
recommendation that ‘sexual intercourse every 2 to 3 days optimises the chance of 
pregnancy’. As this is not typically possible in the case of same-sex couples and 
single people it would not be possible to distinguish underlying problems from 
lifestyle choices as the cause of infertility. Furthermore there are intrinsic problems 
that differentiate the male-male, female-female, single male and single female 
situations that would make a claim of sexual discrimination difficult to defend, most 
particularly the non-funding of surrogacy, a necessary requirement for single male or 
male-male couples. 
 
Should a case be presented where there is a proven cause of infertility, this may 
need to be considered as an individual case, though the problems of potential 
discrimination remain. 
 
2 
Previously privately funded treatment 
 
PCTs have expressed concerns that this policy to fund a cycle even if the couple had 
had up to 2 cycles funded privately, represented inequality of access (based on 
equality of effectiveness and cost effectiveness) as success rates decline with each 
cycle.  It was agreed that couples that met the eligibility criteria and had previously 
funded fewer than 3 cycles should still be offered one NHS funded cycle of IVF/ICSI. 
9
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
Appendix D 
Sub-Fertility Funding Assessment Sheet 
 
Please complete this form for all couples requesting funding for IVF or ICSI.   
 
Patient Name: 
DOB: 
NHS Number: 
Address: 
 
Please indicate true or false dependent on agreement with each criteria 
Criteria 
True 'T' or False 'F' 
Couple has failed to conceive after regular unprotected sexual   
intercourse for 3 years, or have an established cause of infertility.  
Therefore will have been a 'couple' for at least 3 years.  
Female partner is aged 23 to 39 at the start of the treatment   
cycle. 
Neither partner has been previously sterilised. 
 
Female partner has a 20 and 29 
 
Both partners are childless - this means that neither partner are 
 
to have any living children, this includes adopted children. 
The couple’s health and social circumstances would pose no   
significant risk to conception, pregnancy or the resultant child. 
No more than 2 cycles of IVF already received (regardless of   
NHS or privately funded) - couples are only eligible to receive up 
to a maximum of 3 cycles in a lifetime regardless of NHS or 
privately funded. 
Neither partner has previously received NHS funding for a cycle   
of IVF or ICSI. 
 
In addition to couples meeting all of the above criteria, couples 
will not be eligible for further NHS funded cycles if either partner 
have previously received one NHS funded IVF or ICSI cycle 
 
Overall Result (for use by PCT only) 
 
 
 
If couple are approved for funding please specify patients preferred provider:   
CARE or NURTURE at Queens Medical Centre (delete as appropriate) 
 
Completed by:  
 
 
   
Designation:                             
 
Signed: 
     
 
 
Date: 
 
     
 
Please return completed forms to: 
Individual Case Review Committee 
Nottinghamshire County tPCT 
Ransom Hall 
Southwell Road West 
Rainworth 
10
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient IVF Requests 
Appendix F – Assisted Conception Policy 
Revised – May 2008 
Mansfield NG21 0ER 
11
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 - Appendix F Assisted Conception Policy Revised May 
2008.DOC 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX G – TERMS OF REFERENCE FOR THE ICRC 
Revised May 2008 
 
TERMS OF REFERENCE FOR THE INDIVIDUAL CASE REVIEW 
COMMITTEE (ICRC) 
 
1. Constitution 
The Board of Nottinghamshire County tPCT hereby resolves to 
establish a sub-committee to be known as the Individual Case 
Review Committee (ICRC) 
 
2. Membership 
Membership of the ICRC is as follows: 
 
•  2 Non-Executive Directors of PCT (Chair and Deputy 
Chair) 
•  3 GPs 
•  2 senior members of PCT Commissioning & Performance 
Directorate 
•  Chief Pharmacist and deputy 
•  Director of Nursing and Governance and deputy 
•  2 Public Health Consultants 
•  PCT Medical Director 
•  Lay assessor(s)  (once appointed) 
 
In attendance: Individual Case Review Manager 
 
3. Voting rights 
All ICRC members will have the right to vote. If required the 
Chair will have the casting vote. 
 
4. Frequency 
The ICRC will meet monthly. If a case needs to be considered 
urgently between meetings (where the Director of Public 
Health or nominated deputy considers an urgent clinical 
decision is to be made, for example), this will be done by 
telephone, email or fax between the Deputy Director of 
Commissioning & Performance and the Chair with advice from 
the Public Health Consultant / Director of Public Health. In this 
case, decisions taken outside of the meeting will be noted at 
the next scheduled meeting. 
 
5. Authority 
The ICRC is authorised by the PCT Board to make decisions 
on exceptional individual cases only. The ICRC cannot set 
policy by virtue of setting a precedent. 
 
6. Purpose 
To decide whether the PCT should fund treatments outwith 
PCT policy or contracts on the basis of exceptional status. 
 
7. Objectives 
To apply the values of the PCT by addressing the key issues 
of: 
 
•  Legality  
•  Safety  
•  Clinical Effectiveness  
•  Cost Effectiveness  
•  Equity (including equality and diversity) 
•  Accessibility  
•  Affordability  
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 -Appendix G.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX G – TERMS OF REFERENCE FOR THE ICRC 
Revised May 2008 
 
8. Duties 
•  Patient information will be dealt with in confidence: no 
patient identifiable information will be used unless pertinent 
to the consideration of the request. 
•  The ICRC will follow the process described in the Policy on 
the Management of Named Patient Funding Requests May 
2008. 
•  The ICRC will request evidence from the patient’s clinician 
and consider the information received along with 
supplementary information provided by professionals within 
the ICRC. 
•  The ICRC will assess the available evidence on the 
effectiveness and cost effectiveness of the proposed 
investigation/treatment. 
•  The ICRC will co-opt health care practitioners as necessary 
to advise. 
•  The ICRC will record clearly and in detail reasons for its 
decisions. 
•  The ICRC will produce an annual report for the Board, 
relating to activity and finance. 
•  The ICRC will seek information on the outcomes of funded 
treatments. 
•  The ICRC will NOT agree to fund if, in doing so, a 
precedent may be set, that establishes new policy (ie the 
case considered is not exceptional but rather 
representative of a group of patients). Where the ICRC 
feels general access to the service should be provided a 
recommendation should be passed on for consideration 
through the Local Operational Plan processes, but funding 
must be refused. 
•  Where funding is refused and where additional material 
clinical information is provided that was not previously 
available the ICRC will re-consider requests for funding. 
Cases requiring reconsideration will be re-referred to the 
ICRC at its next available meeting. 
•  Where funding is refused and no additional clinical 
information is available, or relevant, the patient may seek 
to appeal the process and policy that have been applied. In 
such circumstances an appeal panel will be convened as 
set out in Appendix H of the Policy I=on the Management 
of Named Patient Funding Requests – May 2008. 
 
9. Quorum 
A minimum of 5, (one Non-Executive Director, one GP, one 
Pharmacy representative, one Nursing & Governance 
representative and one Commissioning representative). 
Exceptionally, the Chair may accept prior assessment and 
contribution by email in lieu of attendance. 
 
10. Attendance 
Directors will ensure attendance to achieve the quorum in 
respect of each department (PCT Chair for Non-Executive 
Directors). 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 -Appendix G.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX G – TERMS OF REFERENCE FOR THE ICRC 
Revised May 2008 
 
 
11. Reporting 
The ICRC will report annually to the Board. 
 
12. Annual Review  The Terms of Reference for the Individual Case Review 
Committee will be reviewed in April of each year. 
 
 
 
 
 
As at 1st April 2008, membership of the ICRC is as follows: 
 
Non-Executive Directors 
Pharmacy 
 
 
Dr Patricia Higham (Chair) 
Cathy Quinn 
Stuart Brooke (Deputy Chair) 
Joe Attewell 
 
Nursing and Governance 
GPs 
 
 
Dr Amanda Sullivan 
Dr Simon Brenchley (Newark) 
Michelle Bateman 
Dr Gaynor Mountcastle (Mansfield) 
Dr Khalid Butt (Mansfield Woodhouse) 
 
Public Health 
Commissioning and Performance 
 
 
Dr Chris Kenny 
Chris Kerrigan 
Dr Clive Richards 
Deborah Jaines 
 
Medical Director 
Lay Assessors 
 
 
Dr Doug Black 
To be appointed 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 -Appendix G.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX G – TERMS OF REFERENCE FOR THE ICRC 
Revised May 2008 
  
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT 
Board\Agenda Papers\2008\May 2008\B08.056 -Appendix G.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX H – APPEALS PANEL  
Revised May 2008 
 
 
1. 
TERMS OF REFERENCE OF THE APPEALS PANEL 
 
1.1 To consider and review the process by which the Individual Case Review Committee’s 
(ICRC) decision in relation to the funding or otherwise of an individual’s 
treatment/service was reached.   The Appeals Panel can consider whether the 
evidence that the Individual Case Review Committee had before it supported the 
decision that was reached and whether there were any circumstances that would have 
warranted the ICRC coming to a different decision. 
 
1.2 In considering the above, the Appeals Panel will use the decision making principles 
(Appendix C) with reference to:  
 
i)  Local policies together with guidance from the Department of Health; Health Service 
Circulars; guidance from NICE and other relevant bodies. 
 
ii)  Oral or written representation from the individual or his or her representative. 
 
iii) Such further information and/or evidence which was produced to the ICRC 
(including the individual’s relevant medical records and comments from the treating 
clinician(s) where provided – subject to provision of the individuals written consent). 
 
1.3 
Where the appellant has provided new or additional evidence that has not been 
previously considered by the ICRC, the Appeals Panel shall refer the case back to 
the ICRC for reconsideration.  The Appeals Panel should not consider evidence that 
has not been subjected to the same rigour and scrutiny that the evidence presented 
to the ICRC has received.  The Appeals Panel will not be permitted to consider a 
case that is reliant on the presentation of new evidence if the case has already been 
reconsidered by the ICRC previously.  Nor will the appeals panel refer this case 
back to the ICRC for a second reconsideration. 
 
1.4 
The Appeals Panel’s decisions are limited to one of five outcomes outlined in 
section 2.17 below. 
 
1.5 
The Appeals Panel will communicate its decision with reasons for its decision to the 
Chairman of the Primary Care Trust and to the appellant as soon as practicable and 
within seven working days of the conclusion of the Appeal hearing in any event. 
 
 
2. 
APPEALS PROCEDURE 
 
This procedure relates to cases where a request for funding of a Named Patient Funding 
Request (NPFR) for an individual has been declined by the PCT’s ICRC.  It does not relate 
to commissioning decisions taken by the PCT for groups or cohorts of patients and 
treatments. 
 
2.1 
Any individual aggrieved by a decision on services or treatment can appeal against 
that decision.  The decision can be challenged on the grounds that it was 
unreasonable1 or not properly based on the evidence set before the ICRC. 
 
                                                 
1 Definition of “unreasonable” for the purposes of this policy is a decision so unreasonable that no 
reasonable authority could have arrived at it. 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 -Appendix H.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX H – APPEALS PANEL  
Revised May 2008 
 
 
The appellant cannot raise new arguments or present new evidence as a ground of 
appeal.  In the event of new evidence becoming available since the ICRC made its 
decision, the patient will be requested to invite his or her clinician to submit that 
evidence to the ICRC so that the case can be duly reconsidered, in accordance with 
the provisions for reconsideration of the Policy on the management of Named 
Patient Funding Requests. 
 
2.2 
The case for which the appeal has been made, must have previously been 
considered by the ICRC.  If this has not occurred, the appeal will be rejected and the 
case referred to the ICRC for consideration.  
 
2.3 
The individual (or the treating clinician on his behalf) must notify the PCT’s Chief 
Executive in writing of his / her appeal, including the grounds for the appeal, within 
twenty-eight working days of the decision of the ICRC being notified to the treating 
clinician.  NB: the ICRC will include the deadline for the appeal in the letter it issues 
when setting out its decision. 
 
2.4 
The appeal letter will be subjected to the following tests prior to a decision being 
taken to set up an oral hearing in front of an Appeal Panel: 
 
•  Has the appeal been submitted within the 28 working day limit ?  If not, and if the 
appellant cannot show reasonable grounds for the delay in making the appeal, the 
appeal will be dismissed as being out of time. 
 
•  Does the appeal raise any new issues that were not part of the original 
consideration by the ICRC, or present new evidence that the ICRC has not had an 
opportunity to consider?  If so then the appeal will be referred back to the ICRC 
for reconsideration in accordance with the policy for Named Patient Funding 
Requests.   
 
•  Does the appeal contain the grounds for the appeal?  If not, the appeal will be 
referred back to the appellant with a request for the grounds to be set out.  In this 
circumstance the appellant will be given a further 14 working days in which to 
resubmit his appeal in proper form.   
 
•  Does the appeal challenge the decision of  the ICRC on the basis that it was 
unreasonable?  If so the appeal will go forward for an oral hearing in front of an 
Appeals Panel. 
 
•  Does the appeal challenge the validity of the decision in relation to the evidence 
that was available when the ICRC made its decision?  If so, the appeal will go 
forward for hearing in front of an Appeals Panel. 
 
 
This screening will be conducted by the Director of Commissioning and 
Performance or a senior manager nominated to perform this task on his/her behalf. 
 
2.5 
If, as a result of the above screening, the appeal is to go forward for an oral hearing 
then, within 5 working days of the decision to convene a panel being taken, the 
Director of Commissioning and Performance, or his/her nominee will issue a 
consent form for the appellant to complete and return.  This consent form enables 
the appellant to give his consent for the Appeals Panel to have full access to all 
relevant information about their case and authorises the Appeals Panel to share 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 -Appendix H.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX H – APPEALS PANEL  
Revised May 2008 
 
information on the case with any person nominated by the appellant in the consent 
form to act on his / her behalf.   
 
The appellant will be asked to return this form within 14 calendar days of receiving 
it.   
2.6 
Upon receipt of a properly completed consent form an Appeals Panel will be 
convened to hear the appeal, and will meet to consider the appeal within 28 days 
unless further relevant information is awaited by one or both of the parties to the 
appeal, in which case one extension of a further 28 days will be considered.  
 
2.7 
The Chief Executive will nominate a PCT officer to convene (The Convening Officer) 
the Appeals Panel and undertake collection and distribution of written material for 
this Panel.  The nominated officer will have no prior knowledge of the case. 
 
2.8 The Appeal Panel will comprise: 
•  One Executive Director of the PCT, who has had no prior involvement in the 
case being appealed. 
 
•  One Non-Executive Director of the PCT, who will Chair the panel, and who has 
had no prior involvement in the case being appealed. 
 
•  The PCT’s Medical Director or Chair of the PEC, or other nominated GP who 
has had no prior involvement in the case being appealed. 
 
The Appeals Panel  must not comprise any member who has had any prior 
involvement in the decision making process.   
 
2.9 
The Convening Officer will invite the appellant to submit written information to the 
Appeals Panel if he / she wishes.  This information should be relevant to the 
grounds of the appeal and should not constitute new or additional evidence not yet 
heard by the ICRC.  If the information is of that nature, the case will be referred back 
to the ICRC for reconsideration in light of the new or additional evidence.  (This will 
only be possible where no reconsideration has previously been made by the ICRC). 
 
2.10  The Convening Officer will invite the appellant’s treating clinician to submit written 
information to the Appeals Panel  if he so wishes (subject to provision of the 
appellant’s written consent).  Again, this information should be in support of the 
grounds for the appeal, and not constitute new or additional evidence.  
2.11 
The Convening Officer will ask the ICRC’s Consultant in Public Health or Specialist 
(who will work with the relevant PCT Lead Officer) to provide in full the information 
on the case that was considered at the ICRC meeting. 
 
2.12  The Appeals Panel  will be provided, prior to its  meeting, with all the written 
information collected by the Convening Officer. 
 
2.13 The 
appellant  will be entitled to make either oral or written representations to the 
Appeals Panel and to be accompanied by a representative(s), or a supporter who 
may make representations on the individual’s behalf. The representative/supporter 
may be the appellant’s treating clinician.  If the appellant chooses not to be present 
or be represented at the Appeal  Panel hearing,  this will not invalidate proceedings 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 -Appendix H.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX H – APPEALS PANEL  
Revised May 2008 
 
and the Appeals Panel will be free to consider the appeal with the information it has 
before it. 
 
2.14 
The appellant shall not be entitled to legal representation at the hearing of his / her 
appeal. 
 
2.15 
The ICRC’s Consultant in Public Health / Specialist or other appropriate PCT Officer 
will attend the Appeals Panel and explain the reasons for the decision made by the 
ICRC. 
 
2.16  In reaching its decision,  the Appeals Panel will pay due regard to the PCT’s 
Decision Making Principles (Appendix C of the Policy on the management of Named 
Patient Funding Requests)  and any relevant clinical and commissioning policies in 
force at the time the request for funding was made. 
 
2.17 
The decisions available to the Appeals Panel are: 
 
a.  To conclude that the decision of the ICRC was properly, logically and rationally 
based on the information that the panel had before it, in which case the appeal 
will be dismissed; and/or 
 
b.  To conclude that the decision arrived at by the ICRC was made on a reasonable 
basis, in which case the appeal will be dismissed; or 
 
c.  To conclude that either the decision of the ICRC was unreasonable (i.e. so 
unreasonable that no reasonably authority could have arrived at it), or the 
decision of the ICRC was not properly based upon the evidence set before that 
Committee, in which case the appeal will be upheld and referred back to the 
ICRC for reconsideration in accordance with the Policy for Named Patient 
Funding Requests; or 
 
d.  To conclude that the appellant has presented new evidence that the ICRC did 
not have an opportunity to consider, in which case the matter will be referred 
back to the ICRC for reconsideration in accordance with the Policy for Named 
Patient Funding Requests; or 
 
e.  To conclude that in light of the evidence heard by the Appeals Panel there are 
grounds for upholding the appeal but that further referral back to the ICRC would 
serve no further purpose, in which case the Appeals Panel will make a 
recommendation to the PCT Board on the appropriate actions to take. 
 
 
It should be noted that the Appeals Panel does not have delegated authority to 
approve expenditure on packages of care and this rests with the ICRC on behalf of 
the Board.  Therefore any final decision on expenditure has to rest with the ICRC or 
the PCT Board. 
 
2.18 
Where a case is referred by the Appeals Panel back to the ICRC the decision of the 
ICRC, after due consideration of the Appeals Panel’s recommendations, shall be 
final and no further appeal shall be allowed.  This is to enable appropriate decisions 
on an individual’s care to be taken and implemented.  Should the individual remain 
dissatisfied with the processes by which their case has been handled they have 
recourse to the PCT’s complaints procedure.  However, it should be noted that the 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 -Appendix H.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX H – APPEALS PANEL  
Revised May 2008 
 
PCT’s complaints procedure does not have the power or authority to overturn a 
decision that has properly been considered by the ICRC and the Appeals Panel. 
 
 
None of the above negates an individual’s rights to refer his case to the Healthcare 
Commission or to the Health Services Ombudsman. 
 
 
3. 
Proceedings at the Appeal Panel hearing 
 
 
The procedure for hearing the appeal will be as follows: 
 
3.1 
The Panel Chair will determine how the appeal will be conducted within the guidelines set 
out below. 
 
3.2 
The Panel Chair will ensure that all parties are introduced. 
 
3.3 
The Panel Chair will ask the appellant and /or the appellant’s representative(s) to explain 
the reasons for the appeal. 
 
3.4 
The Panel Chair will ask the Consultant in Public Health / specialist or attending appropriate 
PCT Officer to explain the ICRC’s decision for refusing the request for funding. 
 
3.5 
The appellant, or his / her representative, may ask the Chair any questions about what has 
been said. 
 
3.6 
The Chair and other panel members may ask those attending the appeal hearing  any 
questions about the case and / or what has been said. 
 
3.7 
The Panel Chair will ask the ICRC’s Public Health Consultant / specialist or appropriate 
PCT Officer to sum up why the ICRC declined to commission (fund) the treatment. 
 
3.8 
The Panel Chair will end the appeal hearing by inviting the appellant or his representative 
to sum up the reasons for the appeal against the decision of the ICRC. 
 
3.9 
All parties other than the Appeals Panel members, will then leave to enable the Appeals 
Panel to consider the merits of the appeal and come to a decision.  Decisions shall be 
reached by a simple majority of the members of the Appeal Panel present at the hearing.  
In the event of an equality of votes, the Chair shall have a casting vote. 
 
3.10 
The Appeals Panel’s decision will be notified by letter from the Panel Chair to the appellant 
within seven working days of the conclusion of the appeal hearing. 
 
3.11  The Panel Chair will, whenever possible arrange for the appellant to be informed by 
telephone of the decision as soon as practicable. 
 
The Chair of the Panel will have the right to vary the above procedure where such 
variations would assist in ensuring the fairness and equity of the panel’s proceedings. 
 
 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 -Appendix H.doc 

---

Policy on the Management of Named Patient Funding Requests 
APPENDIX J – Commissioning Policy – Cosmetic Plastic Surgery Procedures 
Revised – May 2008 
 
 
 
 
 
 
 
 
 
 
 
COMMISSIONING POLICY 
 
COSMETIC PLASTIC SURGERY 
PROCEDURES 
 
May 2008 
 
 
 
 
 
 
 
 
 
Review date: 31 May 2009 
 
 
 
 
 
S:\CORPORATE SERVICES\Nottinghamshire County Teaching PCT Committee Secretariat\Notts County tPCT Board\Agenda 
Papers\2008\May 2008\B08.056 - APPENDIX J - Cosmetic Plastic Surgery Procedures Revised May 2008.doc 

---

 
Introduction 
 
Cosmetic surgery can be defined as any surgery carried out to improve or enhance a 
person’s outward appearance. Although most of the work of plastic surgeons in the NHS is 
to restore appearance and function following trauma, disease or congenital deformity, 
surgery can also be carried out to enhance changes in appearance relating to obesity or 
aging. 
 
The NHS cannot meet all demand  for cosmetic surgery within its current resources. As 
such, the majority of cosmetic surgery procedures are deemed to be ‘low-priority’ and not 
normally funded. This policy sets out the eligibility criteria for access to NHS-funded 
cosmetic surgery procedures. 
 
Patients requiring reconstructive surgery to restore normal or near normal function 
or appearance post-trauma or following cancer treatment do not fall within this 
policy. 
 
 
Background 
 
Although primarily undertaken to enhance outward appearance, many cosmetic surgery 
procedures have the benefit of improving physical dysfunctions that may be considered 
‘clinical’ in their severity. The circumstances in which cosmetic surgery is deemed to be a 
priority and funded are as follows; 
 
Anatomical indications: - if the purpose of the treatment is to alleviate or improve a 
physical deformity that most people would recognise as being severely abnormal 
 
Functional indications: - if the purpose of the treatment is to substantially alleviate or 
improve a physical deformity causing significant and/or prolonged functional problems 
that cannot be resolved effectively by any other appropriate intervention 
 
 
Eligibility criteria for funding are underpinned by the PCT’s decision-making principles  of 
legality, safety, clinical effectiveness, cost effectiveness, equity, accessibility and 
affordability. Criteria for specific procedures were agreed through consultation with key 
stakeholders that included patients and public as well as clinical and non-clinical 
representatives from primary and secondary care organisations in Nottinghamshire 
County. 
 
It is important to note that a substantial proportion of cosmetic surgery is carried out by 
specialties other than plastic surgery, including ENT surgery, ophthalmology, maxillofacial 
surgery, general surgery and dermatology. This policy only concerns procedures carried 
out in NHS hospitals. 
 
 
2

---

 
Referral for cosmetic surgery procedures 
 
Commissioning approval is required for NHS funding of cosmetic surgery procedures. 
Patients who meet the eligibility criteria set out in this policy should be referred for 
treatment via the appropriate pathway. Supporting information should be forwarded with 
each referral, as specified for each procedure in the table below. 
 
Patients who do not meet the eligibility criteria set out in this policy should NOT be 
referred for treatment. 
 
 
Relationship with Individual Case Review Committee (ICRC) 
 
Patients who do not meet the eligibility criteria set out in this policy will not be offered NHS 
funding. If the General Practitioner (GP) and/or patient believe that their case merits 
funding on an exceptional basis, the General Practitioner  will need to; 
•  demonstrate that the patient is significantly different to the general population of 
patients with the condition in question, by being likely to gain significantly more benefit 
from the intervention than might be expected for the average patient with the same 
clinical condition at the same clinical stage.  S 
•  ubmit a named patient funding request to the relevant Primary Care Trust’s ICRC using 
the appropriate route 
. 
 
Appeals mechanism 
 
The appeals mechanism for cosmetic surgery procedures is the same as that for other 
named patient funding requests.  This mechanism exists to provide an opportunity for the 
GP and/or patient to challenge the way the eligibility criteria have been applied. The 
appeals mechanism will not be able to reverse a decision on the basis that the GP and/or 
patient contest the actual criteria for eligibility, which constitutes a formal complaint to the 
PCT’s Chief Executive on commissioning policy. In this case, the formal procedure for 
written complaints is the appropriate route. 
 
 
Monitoring and review 
 
Some aspects of the current policy have changed since the preceding version of the low-
priority treatment and procedures policy was approved by the PCT Board. In order to 
understand the impact of these changes on the number of patients referred, treated and 
having complications, activity against this policy will be monitored closely following 
implementation. Procedure codes have been included in Appendix 1 to assist PCTs in 
identifying hospital activity involving cosmetic surgery procedures. Monitoring will be on a 
weekly basis initially, then monthly or quarterly as appropriate. The policy, including 
eligibility criteria, will be reviewed by April 2009 or before if any new guidance or clinical 
evidence becomes available. 
 
At the time the current policy was reviewed, the Collaborative Commissioning Group of the 
East Midlands Specialised Commissioning Group identified ‘cosmetic surgery’ as a 
 
3

---

 
regional priority that required a collaborative approach. On that basis, it is anticipated that 
a regional cosmetic surgery policy will replace the current local policy at some future date. 
 
 
General Eligibility 
 
It is the purpose of eligibility criteria to make the limits on NHS-funded cosmetic surgery 
fair, clear and explicit to patients, providers and commissioners alike. 
 
1.  Surgery for patients who are deemed to be within the normal morphological range will 
be considered purely cosmetic and therefore NOT funded on the NHS. 
2.  Referrals for the revision of treatments originally performed outside the NHS will NOT 
normally be supported and patients should be referred back to the practitioner who 
carried out the original procedure. However there may be unusual or severe 
complications or circumstances that require the transfer of a patient to the NHS for 
appropriate management. 
3.  Patients previously treated within the NHS should be considered for revision surgery 
based on clinical need and priority. 
4.  Cosmetic surgery procedures will NOT be funded to alleviate psychological distress or 
dysfunction. No exceptions to this policy are foreseen. When there is particular concern 
over psychological well-being, patients should be referred to the appropriate service for 
psychological assessment and/or support. 
5.  Surgical outcomes (e.g. wound healing, complications etc) can be adversely affected 
by smoking. To ensure the best outcomes, patients should have stopped smoking prior 
to referral. Smoking status may be validated at pre-operative appointment using an 
appropriate test. Support to stop smoking is available to patients through a range of 
NHS stop smoking services. 
6.  All decisions will be taken in the context of the overall financial position of the PCT. 
 
 
4

---

 
Eligibility for Specific Procedures 
 
General Surgical Procedures 
 
Procedure 
Eligibility criteria 
Information to forward with referral 
Abdominoplasty and/or 
Referral only for patients who; 
•  Details of condition 
thigh and arm lift 
•  have a BMI between 18 and 27 that has been maintained for at least 2 years  •  BMI and period maintained 
surgery (following 
AND 
•  Weight loss in BMI points 
significant weight loss) 
•  have lost a significant amount of weight that is equivalent to at least 10 BMI 
•  Smoking status 
points AND 
•  Clinical evidence of severe 
•  are experiencing severe difficulties with daily living e.g. ambulatory or 
difficulties with daily living 
urological restrictions 
•  Clinical photographs 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
BMI should be measured in the NHS. When there is a disabling affect upon daily 
living, patients may be eligible for contouring at diabetes injections sites (upon 
recommendation of Diabetologist) or for lymphoedema, thinning of skin flaps or 
post-gastric partitioning. Female patients planning a family should postpone 
treatment until after childbirth. 
 
Blepharoplasty (eyelid 
Referral only for patients whose upper eyelid significantly interferes (due to 
•  Details of condition 
reduction) 
ptosis or excessive skin) with their vision field (as assessed by an Optometrist 
•  Results of optometry assessment 
prior to referral). Lower eyelids are excluded as they do not obscure vision. 
•  Smoking status 
 
•  Clinical photographs 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
 
5 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Botulinum toxin 
Approved for the treatment of the following pathological conditions by 
•  Details of condition 
injections 
appropriate specialists; 
•  Smoking status 
•  Axillary hyperhidrosis (refer to Dermatology for consultant assessment) 
•  Blepharospasm (refer to Plastic Surgery for consultant assessment) 
 
Not available for the treatment of facial aging or excessive wrinkles. 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Breast asymmetry 
Referral only for patients with gross asymmetry who; 
•  Details of condition 
•  are aged 16 years or over AND 
•  Age 
•  have a BMI between 18 and 25 AND where; 
•  Smoking status 
•  there is gross asymmetry equal to or greater than 30% difference in breast 
•  BMI 
volume 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
BMI should be measured in the NHS. Patients will be offered a 3D body scan1 to 
objectively measure breast volume and the extent of breast asymmetry. 
 
                                            
1 Body Aspect Limited provides the 3D body scanning service. Scanning uses white light technology to accurately measure volumes within sections of the body. A 
female operator will undertake the body scanning. Body Aspect Limited will produce a report of scan results that will be returned to the PCT’s pathway co-ordinator 
and considered against the eligibility criteria along with other information. Scan results will also be used by the surgeon as part of the pre-treatment counselling with 
the patient and during surgery to assist with the corrective procedure. 
 
6 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Breast augmentation 
Not routinely funded for cosmetic reasons. Breast augmentation may be an 
See breast asymmetry 
appropriate treatment for breast asymmetry in some women (see appropriate 
criteria). 
 
Breast reconstruction is always supported following mastectomy. 
 
Breast mastopexy 
Not routinely funded for cosmetic reasons (e.g. post-lactation or age-related 
See breast reduction or breast 
(surgical fixation of the 
breast ptosis). Breast mastopexy may be an appropriate treatment for breast 
asymmetry 
breast) 
asymmetry or breast reduction in some women (see appropriate criteria). 
 
Breast reduction 
Referral only for patients with abnormally large breasts who; 
•  Details of condition 
•  are aged 16 years or over AND 
•  Age 
•  have a BMI between 18 and 25 AND where; 
•  BMI 
•  breast size is equal to or greater than 1000cc per breast AND 
•  Smoking status 
•  the ratio of combined breast volume to adjusted partial torso volume is equal 
to or greater than 13% 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
BMI should be measured in the NHS. Treatment is supported based on the 
known relationship between large breasts and spinal disorders. Patients will be 
offered a 3D body scan to objectively measure breast volume. 
 
 
7 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Breast reduction (male 
Referral only for male patients who; 
•  Details of condition 
gynaecomastia) 
•  are post-pubertal AND 
•  Pubertal status 
•  have a BMI between 18 and 25 AND where; 
•  Smoking status 
•  there is excessive breast tissue and the expected reduction to be obtained 
•  BMI 
will be significant and/or there is gross asymmetry 
•  Results of endocrinological 
 
assessment 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
•  History of sport performance-
affected by smoking. To ensure the best outcomes, patients should have 
enhancing drug use 
stopped smoking prior to referral. Smoking status may be validated at pre-
•  Clinical photographs 
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
BMI should be measured in the NHS. In the first instance, patients should be 
referred for assessment by an Endocrinologist. Patients will not be offered a 3D 
body scan to objectively measure breast volume as a local trial has shown 
scanning to be insufficiently sensitive for male gynaecomastia. 
 
Individuals who are taking sport performance-enhancing drugs (in whom the 
gynaecomastia is potentially drug-induced) will be refused surgery and should 
not be referred. 
 
Correction of 
Not funded for cosmetic reasons. This common condition responds well to non-
Not funded for cosmetic reasons 
congenital nipple 
surgical interventions e.g. Niplette device. 
inversion 
 
Note that any recent nipple inversion should be considered as suggestive 
of breast cancer and requires referral to a breast surgeon. 
 
 
8 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Dermabrasion Referral 
only following trauma, acne, discoid lupus or other scarring facial skin 
•  Details of condition 
diseases. Patients should be referred to Dermatology. Patients will be jointly 
•  Smoking status 
assessed by a consultant dermatologist and a consultant plastic surgeon. 
•  Clinical photographs 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Face or brow lift 
Referral only for the surgical correction of facial palsy or deformities following 
•  Details of condition 
trauma or surgery if other treatments are not appropriate. A consultant will 
•  Smoking status 
assess the patient and make a clinical decision in each case. 
•  Clinical photographs 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Hair depilation (for 
Referral only for patients with excessive and intractable facial hair that; 
•  Details of condition 
hirsutism, especially in 
•  is a recognised component of a clinical condition OR 
•  Smoking status 
women) 
•  has been caused by drug therapy OR 
•  Clinical photographs 
•  is idiopathic and could be considered grossly abnormal 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Patients who have undergone reconstructive skin grafting surgery that has led to 
abnormally located hair-bearing skin will be treated outside of this policy. 
 
 
9 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Hair transplantation 
Not funded for cosmetic reasons. Patients requiring reconstruction of the 
Not funded for cosmetic reasons 
eyebrow following cancer or trauma will be treated outside of this policy. 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Liposuction Liposuction 
supported 
only when used in the management of lipodystrophies, 
•  Details of condition 
large lipomas, fat injuries due to trauma, lymphoedema or as part of other 
•  Smoking status 
surgery (e.g. thinning of transplanted flap). 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
 
10 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Pinnaplasty (correction 
Referral only for children; 
•  Details of condition 
of prominent ears) 
•  aged 5 to 18 years at the time of referral AND 
•  Age 
•  with very significant ear deformity or asymmetry AND 
•  Smoking status 
•  where the child, rather than the parents alone, expresses concern 
•  Clinical photographs 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Referral of patients over the age of 18 years is considered inappropriate and will 
not be funded. 
 
Removal and 
Removal of intact or ruptured silicone implants or scar tissue and replacement of  •  Details of condition 
replacement of silicone 
silicone implants are not routinely available on the grounds of concern over 
•  Clinical evidence of physical 
implants (including 
excess risk of connective tissue disorders2. 
problems or gross deformity 
Capsular contraction 
 
•  Responsibility for implant operation 
following aesthetic 
All patients will be assessed to rule out any underlying cancers. 
•  Smoking status 
augmentation) 
 
Removal will be offered only if the implants are causing physical problems with 
everyday life or where the patient has gross deformity. Replacement will be 
offered only if the implant operation was performed in the NHS (e.g. correction 
of breast asymmetry or reconstruction following breast cancer) and the patient 
meets eligibility criteria for augmentation at the time of revision. 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
                                            
2 Following the recommendations of the Department of Health’s (DH) advisory group (Gott and Tinkler 1994) and Independent Review Group (1998) on silicone gel 
breast implants and considering the published conclusion that silicone breast implants are not associated with meaningful excess risk of connective tissue disease 
(Cooper and Dennison 1998, Nyren et al 1998) 
 
11 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Revision mammoplasty  Referral only if the; 
•  Details of condition 
(second surgical 
•  implants are causing physical problems with everyday life or where the 
•  Clinical evidence of physical 
alteration of breast size 
patient has gross deformity AND 
problems or gross deformity 
or shape) 
•  implant operation was performed in the NHS (e.g. correction of breast 
•  Responsibility for implant operation 
asymmetry or reconstruction following breast cancer) 
•  Smoking status 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Rhinoplasty Referral 
only for patients with; 
•  Details of condition 
•  congenital (e.g. cleft palate) or post-traumatic deformity (refer to Plastic 
•  Clinical evidence of deformity or 
Surgery for consultant assessment) AND/OR 
airway problems 
•  significant airway problems (refer to ENT for consultant assessment) 
•  Smoking status 
 
•  Clinical photographs 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
 
12 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Scar revision 
Referral only for treatment of scars, following burns, trauma, keloid formation or 
•  Details of condition 
post-surgical complications, which interfere with function. The primary concern 
•  Smoking status 
with this procedure is whether surgery is clinically appropriate and expected to 
•  Clinical photographs 
achieve significant benefit. 
 
Large lesions that cause extreme facial disfigurement may be eligible if the 
proposed procedure is assessed as clinically appropriate and expected to 
achieve significant health benefit. The risks of scarring must be balanced against 
the appearance of the lesion. 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Tattoo removal 
Referral only for patients with tattoos that; 
•  Details of condition 
•  are the result of trauma AND/OR 
•  Smoking status 
•  are the source of a significant allergic reaction 
•  Clinical photographs 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
 
 
 
 
 
 
 
 
 
 
13 

---

 
Excision of Skin Lesions 
 
Procedure 
Eligibility criteria 
Information to forward with referral 
Benign skin lesions 
Treatment of the following benign lesions with no risk of malignancy or infection 
•  Details of condition 
is considered to be purely cosmetic and should not be referred; 
•  For suspect lesions, copy of skin 
•  Benign naevi 
clinic letter 
•  Haemangiomas 
•  Smoking status 
•  Seborrhoeic warts 
•  Clinical photographs 
•  Skin tags 
•  Spider naevi 
•  Thread veins 
•  Warts (please see specific criteria below) 
•  Xanthelasma 
 
Patient anxiety is not a sufficient reason for referral. For a consultant opinion, 
refer benign lesions that are symptomatic (e.g. discharging or recurrently 
infected), problematic (e.g. functionally disabling or subject to trauma) or if there 
is diagnostic doubt. 
 
Refer urgently all lesions suspected of malignancy. A copy of the skin clinic 
letter should be attached that explains to the patient that the lesion will not be 
treated should it be found to be benign. 
 
Large lesions that cause extreme facial disfigurement may be eligible if the 
proposed procedure is assessed as clinically appropriate and expected to 
achieve significant health benefit. The risks of scarring must be balanced against 
the appearance of the lesion. 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
 
14 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Lipomas 
Lipomas less than 5cms should be observed only using the soft tissue sarcoma 
•  Details of condition 
guidelines (SIGN 2003), unless symptomatic (e.g. discharging or recurrently 
•  Smoking status 
infected) or problematic (e.g. functionally disabling or subject to trauma). 
•  Clinical photographs (showing size 
Lipomas located on the body should be referred to the sarcoma clinic if 
of lipoma) 
they are over 5cms in diameter or if they are in a sub-fascial position. 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Rhinophyma 
The first line treatment of this condition is medical. Referral for surgery or laser 
•  Details of condition 
treatment only for severe cases that cause extreme facial disfigurement and do 
•  Smoking status 
not respond to medical treatment. 
•  Clinical photographs 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
 
15 

---

 
Procedure 
Eligibility criteria 
Information to forward with referral 
Sebaceous (epidermal)  An appropriate specialist will treat these lesions. Referral only for patients with 
•  Details of condition 
cysts 
cysts; 
•  Smoking status 
•  of any size that are symptomatic (e.g. discharging or recurrently infected) or 
•  Clinical photographs (showing size 
problematic (e.g. functionally disabling or subject to trauma) 
of cyst) 
•  over ½ cm on the eyelid (refer to Ocular Plastic Surgeon) 
•  over 1cm on the face 
•  over 2cm on the body 
•  over 1cm prominence on the scalp 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
stopped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
Warts 
Warts should normally be treated in primary care if it is deemed that treatment is 
•  Details of condition 
needed (warts usually being self-limiting). However, treatment of warts on the 
•  Smoking status 
margins of the eyelids is problematic and these should be referred to Plastic 
•  Clinical photographs 
Surgery for treatment. 
 
Surgical outcomes (e.g. wound healing, complications etc) can be adversely 
affected by smoking. To ensure the best outcomes, patients should have 
s`topped smoking prior to referral. Smoking status may be validated at pre-
operative appointment using an appropriate test. Support to stop smoking is 
available to patients through a range of NHS stop smoking services. 
 
 
 
References 
 
Cooper C and Dennison E. 1998. Do silicone breast implants cause connective tissue disease? BMJ 1998;316:403-404. 
 
Gott DM and Tinkler JJB. Evaluation of evidence for an association between the implantation of silicone and connective tissue 
disease. London: Medical Devices Agency, 1994. 
 
 
16 

---

 
Independent Review Group. Silicone gel breast implants: the report of the Independent Review Group. London: Medical Devices Agency, 
1998. 
 
Nyren O, Yin L, Josefsson S, McLaughlin J K, Blot W J, Engqvist M, et al. Risk of connective tissue disease and related disorders among 
women with breast implants: a nation-wide retrospective cohort study in Sweden. BMJ 1998;316:417-22. 
 
Worcestershire PCT. 2007. Commissioning policy. Aesthetic surgery. Worcestershire PCT. May 2007 
 
 
 
17 

---

 
APPENDIX 1. OPCS 4 procedure codes and ICD-10 diagnosis codes for cosmetic surgery procedures (based on mapping by 
Bedfordshire Heartlands PCT and discussion with the clinical coding team at Nottingham University Hospitals NHS Trust). 
 
General Surgical Procedures 
 
Procedure 
OPCS 4 procedure codes 
ICD-10 diagnosis codes 
Abdominoplasty and/or thigh S02.1 Plastic excision of skin of abdominal wall, Abdominoplasty 
 
and arm lift surgery 
S02.2 Plastic excision of skin of abdominal wall, Abdominolipectomy 
(following significant weight  S03.1 Plastic excision of skin of other site, Buttock lift 
loss) 
S03.2 Plastic excision of skin of other site, Thigh lift 
S03.3 Plastic excision of skin of other site, Excision of redundant skin or fat of arm 
Blepharoplasty (eyelid 
C13.1 Excision of redundant skin of eyelid, Blepharoplasty of both eyelids 
 
reduction) 
C13.2 Excision of redundant skin of eyelid, Blepharoplasty of upper eyelid 
C13.3 Excision of redundant skin of eyelid, Blepharoplasty of lower eyelid 
C13.4 Excision of redundant skin of eyelid, Blepharoplasty nec 
C13.8 Excision of redundant skin of eyelid, Other specified 
C13.9 Excision of redundant skin of eyelid, Unspecified 
Botulinum toxin injections 
Specific procedure not known 
 
Breast asymmetry 
Diagnosis. Included within breast augmentation or reduction 
 
Breast augmentation 
B31.2 Other plastic operations on breast, Augmentation mammoplasty 
 
B30.1 Prosthesis for breast, Insertion of prosthesis for breast 
B30.2 Prosthesis for breast, Revision of prosthesis for breast 
B30.3 Prosthesis for breast, Removal of prosthesis for breast 
B30.8 Prosthesis for breast, Other specified 
B30.9 Prosthesis for breast, Unspecified 
Breast mastopexy (surgical  B31.3 Other plastic operations on breast, mastopexy 
 
fixation of the breast) 
Breast reduction 
B31.1 Other plastic operations on breast, Reduction Mammoplasty 
 
Breast reduction (male 
B31.1 Other plastic operations on breast, Reduction Mammoplasty 
 
gynaecomastia) 
 

---

 
Procedure 
OPCS 4 procedure codes 
ICD-10 diagnosis codes 
Correction of congenital 
B35.1 Operations on nipple, Transposition of nipple 
 
nipple inversion 
B35.2 Operations on nipple, Excision of nipple 
B35.3 Operations on nipple, Extirpation of lesion of nipple 
B35.4 Operations on nipple, Plastic operations on nipple 
B35.5 Operations on nipple, Biopsy of lesion of nipple 
B35.6 Operations on nipple, Eversion of nipple 
B35.8 Operations on nipple, Other specified 
B35.9 Operations on nipple, Unspecified 
Dermabrasion 
S60.1 Dermabrasion of skin of head or neck 
 
S60.2 Dermabrasion of skin nec 
S01.1 Plastic excision of skin of head or neck, Facelift and tightening of platysma 
S01.2 Plastic excision of skin of head or neck, Facelift nec 
Face or brow lift 
 
S01.3 Plastic excision of skin of head or neck, Submental lipectomy 
S01.4 Plastic excision of skin of head or neck, Browlift 
Hair depilation (for hirsutism, S10.4 Other destruction of lesion of skin of head or neck, Electrolysis to lesion of skin  L68* Hirsutism 
especially in women) 
of head or neck 
S11.4 Other destruction of lesion of skin of other site, Electrolysis to lesion of skin nec
S06.5 Other excision of lesion of skin, Excision of lesion of skin of head or neck nec 
S06.8 Other excision of lesion of skin, Other specified 
S06.9 Other excision of lesion of skin, Unspecified 
Hair transplantation 
S33 Hair bearing graft of skin to scalp 
 
S34 Hair bearing graft of skin to other site 
Liposuction 
S62.1 Other operations on subcutaneous tissue, Liposuction of subcutaneous tissue of  
head or neck 
S62.2 Other operations on subcutaneous tissue, Liposuction of subcutaneous tissue 
nec 
Pinnaplasty (correction of 
D03.3 Plastic operations on external ear, Pinnaplasty 
 
prominent ears) 
Revision mammoplasty (a 
B31.4 Other plastic operations on breast, revision of mammoplasty 
 
second surgical alteration of  B30.2 Prosthesis for breast, Revision of prosthesis for breast 
the breast size or shape) 
Rhinoplasty 
E02.3 Plastic operations on nose, Septorhinoplasty using implant 
 
E02.4 Plastic operations on nose, Septorhinoplasty using graft 
E02.5 Plastic operations on nose, Reduction rhinoplasty 
E02.6 Plastic operations on nose, Rhinoplasty nec 
 

---

 
Procedure 
OPCS 4 procedure codes 
ICD-10 diagnosis codes 
Scar revision 
S60.4 Refashioning of scar NEC 
 
Tattoo removal 
S09.1 Photodestruction of lesion of skin, Laser destruction of lesion of skin of head or  L81.8 Other specified disorders of 
neck 
pigmentation 
S09.2 Photodestruction of lesion of skin, Laser destruction of lesion of skin nec 
S06.5 Other excision of lesion of skin, Excision of lesion of skin of head or neck nec 
S06.8 Other excision of lesion of skin, Other specified 
S06.9 Other excision of lesion of skin, Unspecified 
 
 
Excision of Skin Lesions 
 
Procedure 
OPCS 4 procedure codes 
ICD-10 diagnosis codes 
Benign skin lesions 
S06.5 Other excision of lesion of skin, Excision of lesion of skin of head or neck nec 
Examples (no specific codes) 
S06.8 Other excision of lesion of skin, Other specified 
D23* Other benign neoplasms of 
S06.9 Other excision of lesion of skin, Unspecified 
skin 
S09.1 Photodestruction of lesion of skin, Laser destruction of lesion of skin of head or  D17* Benign lipomatous neop 
neck 
skin/subcut tis 
S09.2 Photodestruction of lesion of skin, Laser destruction of lesion of skin nec 
D22* Melanocytic naevi 
L82.X Seborrhoeic keratosis 
H02.6 Xanthelasma of eyelid 
I78.1 Naevus non-neopastic 
I78.8 Other diseases of capillaries 
Lipomas 
Diagnosis. Specific procedure not known 
 
Rhinophyma 
Diagnosis. Specific procedure not known 
 
Sebaceous (epidermal) 
S06.5 Other excision of lesion of skin, Excision of lesion of skin of head or neck nec 
L72.0 Epidermal cyst 
cysts 
S06.8 Other excision of lesion of skin, Other specified 
S06.9 Other excision of lesion of skin, Unspecified 
Warts 
Diagnosis. Specific procedure not known 
 
 
 

---