Appeals process as of 5 September 2017 - policy ratified by CCG Governing Body on this date. Read the full policy on the Exceptional and Individual Funding page
to find out more.
Appeals will be considered at three stages as follows:
First Stage: Reconsideration of the decision (appeal by Fortnightly Review Panel (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 Fortnightly Review (FR) Chair and the patient. The FR Chair 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 Chair 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 FR Chair 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: Clinical Executive Committee (CEC) Review
A request for review of the decision can be made by the Applicant, the patient or their carer or relative. The request must be supported by the referring clinician who must explain the reasons for the review.
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 CEC Review forms part of the CCG’s corporate governance process - CEC includes GPs and Executive Directors of the CCG. It 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 by the CEC and there will be no representation by either the Applicant, the patient or their carer or relative. The FR Panel GP Chair or Deputy will attend the CEC to present and answer any questions relating to the case as required.
In reviewing the decision, the CEC will consider the following:
- Whether the process followed by the FR Panel was consistent with the CCG’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 CCG;
• had taken into account and considered all the relevant evidence;
• had not taken into account irrelevant factors;
• was a decision which a reasonable IFR Panel was entitled to reach.
The CEC will make one of the two following decisions:
The Chair of the CEC will write to the Applicant (the minute/note of CEC will inform the response and the Exceptional Cases Administrator will work up the response letter on behalf of the Chair of CEC) and the patient or their carer or relative informing then of the outcome and the reasons for the CEC’s 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 the CCG 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 by the CEC to the Clinical Priorities Forum via the Secretary to review the policy and request a report once the policy is reviewed.