What is exceptional funding?
An Exceptional Funding Request (EFR) is the route by which your health professional can apply on your behalf for treatments, drugs and devices (collectively referred to as interventions) that we do not routinely fund.
There are two situations where we do not routinely commission an intervention. These are where:
- we do not commission the intervention for anyone with this condition
- the patient does not meet the criteria set out in the commissioning policy for this intervention.
Your health professional will be able to identify if the EFR process applies to you, if they assess you to have a medical condition that is ‘clinically exceptional’, i.e. you have a set of circumstances that are very different from anyone else with the same, or a similar condition. If this is the case, they may complete an EFR application form and send it to us. If enough evidence has been provided your case will be considered at an EFR panel meeting.
The Exceptional Funding Requests panel, who meet monthly, is a small group of health professionals, including GPs, Public Health representatives and a Lay person (patient representative).
The panel can either agree to fund your intervention, seek more information or decline to fund the request. They will send a letter to both you and your doctor outlining the panel’s decision within 5 working days of the meeting.
What is clinical exceptionality?
To be eligible for consideration as an Exceptional Funding Request, a case needs to be made by your referring clinician on medical grounds because:
- you have a medical condition or clinical presentation which is considered to be rare i.e. we would not expect to see more than one other patient in the same or similar circumstances in its geographical area within a 12 month period, unless similar patients were from the same family group, which may occur in the context of a rare genetic disease and that we do not have an explicit commissioning policy because this is not warranted by the low probability of the condition occurring among our population. This is the criterion on ‘Rarity’.
- or where we do not routinely commission the intervention for you because you do not meet the specific criteria, your referring clinician may put forward a case that you are clinically exceptional by demonstrating that (a) you are significantly different in some clinical manner from the cohort of patients with the same condition at the same stage of progression for whom we do not fund the intervention and (b) you are likely to gain significantly more clinical benefit from the intervention than that cohort. This is the criterion of ‘clinical exceptionality’.
We have developed an Ethical Framework for decision-making to demonstrate consistency across all aspects of commissioning.
This form must be completed when applying for treatments that are not normally commissioned by the CCG.
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