Appeals

Appeals process as of 2 November 2021 -  the  Exceptional and Individual Funding Requests Policy [docx] 766KB was ratified by Cambridgeshire and Peterborough CCG Governing Body on this date.  This policy has been adopted by NHS Cambridgeshire & Peterborough (ICB).

Appeals will be considered at three stages as follows:

First Stage: Reconsideration of the decision (appeal by Fortnightly Review Panel or FR Panel)

If the FR Panel declines funding for a treatment, or approves it subject to conditions and the applicant and or the patient is not satisfied with the outcome, the applicant may have the option of having the request reconsidered. The request for reconsideration must be supported by new clinical information.

The exceptional cases/individual funding request manager and Chair of the FR Panel will screen the additional information submitted to support the reconsideration request to determine whether it significantly alters the nature or strength of the evidence originally submitted to the Panel.  If it does the request will be resubmitted to the next available FR Panel meeting which will consider the new information alongside the original request. 

Second Stage: One-to-One Meeting

For a patient who wishes to appeal further, a one to one meeting will be offered between the most appropriate clinical lead and the patient.  The Clinical Lead will attend the meeting with a member of the Panel Office Team.  The patient is entitled to bring along a family member or representative for this meeting.  The purpose of the meeting is for the Clinical Lead to explain the Commissioning Authority policy and process, and the reasons that the FR Panel reached its decision not to approve funding.  It also allows the Clinical Lead to listen to the concerns of the patient and answer any queries they may have.  In rare circumstances it also gives an opportunity for the patient to provide any new information that was not presented to the FR Panel before. 

Following the one to one meeting, the case will be referred back to the next available Fortnightly Review Panel meeting to acknowledge the one-to-one meeting held and to reconsider any new information that may have been provided.  The applicant will be advised of the decision by FR Panel. 

Third Stage:  Chief Nurse and Medical Director Review

A request for review of the decision can be made by the Applicant, the patient or their carer or relative.  The reason for the review must be one of the following.

• that the decision of the Panel was procedurally improper; and/or 

• the decision of the Panel was not based on the use of the correct policy; and or

• that the decision of the Panel, was in the opinion of the referring clinician, one which no reasonable panel could have reached (if this challenge and its reasoning has been put to the panel after the initial assessment, appeal or one to one meeting and the panel disagrees in its reconsideration).

The Chief Nurse and Medical Director Review forms part of NHS Cambridgeshire & Peterborough's corporate governance process.  They will consider the grounds for the review request and will examine all the documentation considered by the FR Panel, the case file of the meeting at which the decision was made and the decision letter.  No new written or oral information will be considered and there will be no representation by either the Applicant, the patient or their carer or relative.

In reviewing the decision,  the Chief Nurse and Medical Director will consider the following:

• Whether the process followed by the FR panel was consistent with the ICB's Corporate Governance Arrangements.

• Whether the decision reached by the FR Panel:

  • was taken following a process which was consistent with the policies of the ICB;

  • had taken into account and considered all the relevant evidence;

  • had not taken into account irrelevant factors;

  • was a decision which a reasonable FR Panel was entitled to reach.

The Chief Nurse and Medical Director will make one of the two following decisions:  

• To uphold the decision made by the FR Panel.  They will be able to choose this option even if it considers there have been procedural errors or inconsistency with applying commissioning policy, if it believes that there would not be a prospect of the requested treatment being approved by the FR Panel, if it were to reconsider the case.

• To refer the case back to the FR Panel with detailed points for reconsideration.  The case will then be considered at the next scheduled meeting of the relevant FR Panel.

The Chief Nurse and Medical Director will write to the Applicant and the patient or their carer or relative informing them of the outcome and reasons for the decision.  If the FR Panel decision has been upheld, the letter will provide details of the right of the Applicant or patient or their carer or relative to complain to NHS Cambridgeshire & Peterborough (the ICB) about the policy, but any complaint about the process or the decision should be made to the Parliamentary and Health Service Ombudsman.

Any challenges to the Clinical Priorities Policies or statements will be referred the Clinical Priorities Forum via the Forum Secretary to review the policy and request a report once the policy is reviewed.