14. Before we decide if we should investigate a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and, we have not found any indications that something has gone wrong.
The CCG wrongly changed its criteria for epidural injections
15. Mr M’s clinical records show funding requests for epidural injections were accepted up to, and including, 25 September 2019. The records show the last epidural injection was administered on 11 December 2019. The records show the CCG told Mr M he was no longer eligible for epidural injections on 6 February 2020.
16. To investigate Mr M’s complaint, we have looked at the policy the CCG had in place at the time.
17. The CCG’s Service Restriction Policy (SRP) (July 2018) says its purpose is to ensure the CCG funds treatment, only for clinically effective interventions, to the right patients. The SRP says it makes decisions based on clinical and cost effectiveness. It also takes into account relevant national standards. The SRP lists procedures and services that the CCG restricts funding for. This includes epidural injections for lower back pain. The SRP says it will commission epidural injections when one of the following criteria are met.
· The patient has undergone discectomy – a single injection will be commissioned.
· Patient has acute (up to 12 weeks duration) and severe sciatica and is being treated as part of an integrated MSK pain management pathway
18. The SRP also says epidural injections are not commissioned for patients who have non-specific / axial low back pain, or patients with failed back pain surgery syndrome.
19. In its complaint response, the CCG said in order to manage its funds it must make decisions, based on clinical evidence, as to what interventions can be funded when people wish to use healthcare services.
20. In its complaint response the CCG also said epidural injections are considered a PLCV, which national experts suggest have only limited or temporary benefit. The CCG said it considered the case and evidence from Nottinghamshire CityCare Partnership’s MOSAIC Team. The CCG said there was no evidence that Mr M met the eligibility criteria.
21. We have looked at whether the CCG has changed its policy and the process it followed to come to its decision not to routinely fund the treatment.
22. We understand the CCG’s current SRP was approved in July 2018, and this is the relevant policy in this case. We understand this policy replaced several previous policies which are not readily available to view. As the 2018 policy replaces previous ones, it is not necessary or proportionate for us to consider these.
23. We understand the CCG continued to fund Mr M’s epidural injections until December 2019. Mr M therefore benefitted from the treatment for longer than the policy allowed.
24. There is nothing to say that the CCG was wrong to change or update its policy in July 2018. We understand a CCG may change its policy when national clinical guidance is updated. A CCG may update its policy to amend funding criteria for one, or a number of treatments.
25. From the information we have seen in the SRP and the complaint response, it appears the CCG followed its process in reaching its decision not to routinely fund the epidural injections. The CCG said it obtained the relevant clinical evidence in order to determine if Mr M’s case met the eligibility criteria. The CCG has acted in line with The Ombudsman’s Principles of Good Administration (‘Getting it right’ section). The CCG followed its own policy, acted in accordance with recognised clinical standards, and considered the evidence appropriately when reaching its decision. We have therefore seen no indications of failings.
The CCG wrongly declined the Individual Funding Request (IFR)
26. In its complaint response the CCG directed Mr M to its Individual Funding Request (IFR) if he felt his case should be considered outside the usual process.
27. An IFR is a request to fund a treatment that falls outside the range of services and treatments a CCG has agreed to routinely provide. We understand when a CCG receives an IFR, it first looks to see whether the request for funding is covered by a specific funding policy and, if it is, whether the patient meets the criteria of that policy. If an IFR does not meet the criteria, the CCG will then look to see if there are exceptional clinical circumstances.
28. The CCG’s IFR Commission Policy (April 2020) says it considers the following issues when determining exceptionality:
29. Are there any clinical features of the patient’s case which make the patient significantly different to the general population of patients with the condition in question at the same stage of progression of the condition?
30. Would the patient be likely to gain significantly more clinical benefit from the requested intervention than might be normally expected for the general population of patients with the condition at the same stage of the progression of the condition?
31. Mr M’s IFR application was submitted by his GP on 20 August 2020. The GP described Mr M’s diagnosis, and clinical background, of chronic back pain with multi-level facet joint and disc involvement, leading to severe ongoing pain and reduced mobility. The GP also said why Mr M’s case was exceptional.
32. In its response dated 8 September 2020, the CCG said for an IFR to be considered it needed to see evidence that:-
33. An individual patient has an exceptional ability to gain significantly greater clinical benefit than other patients with the same condition and stage of condition; Or
34. Be for a rare condition, such as that there would be insufficient patient numbers for NHS policy to be developed.
35. When looking at individual funding decisions, our role is not to reach a new decision on whether funding is appropriate, and we are not reaching our own view on whether someone has demonstrated exceptionality. Instead, we look at the process the CCG followed to come to its decision. It is only if we see failings in the way the CCG reached its decision that we can consider asking it to look at the funding request again.
36. The CCG said it had declined Mr M’s request for individual funding. The CCG said based on the evidence there was nothing to suggest Mr M’s case was exceptional. The CCG said the information in the IFR application did not demonstrate that Mr M was significantly clinically different to the group of patients either with the same condition, or at the same stage of progression of the condition.
37. The CCG said to be eligible for consideration, a case needed to be made by a referring clinician who could clearly evidence clinical exceptionality. The CCG said the IFR was considered by the IFR Manager and a Consultant in Public Health. The CCG decided that the clinical opinion was not evidence of how Mr M’s case was different to the cohort of similar patients, and so exceptional circumstances were not demonstrated.
38. From the information we have seen, it appears that the CCG has fully considered all the information provided as part of the IFR and has followed its policy when reaching its decision. We can see evidence in the documents the CCG sent us that its funding panel did consider the supporting evidence before coming to its decision.
39. This means we are not able to ask the CCG to revisit its funding decision as we have seen no indications of a failing.
The CCG misrepresented its Accountable Officer as a doctor in its complaint response
40. The CCG’s complaint response dated 30 July 2020 is signed by its Accountable Officer, Dr S.
41. The CCG’s lists its governing body members on its website. Dr S is listed and is described as an Accountable Officer. The profile section says Dr S was awarded a PhD (Doctor of Philosophy).
42. We understand a person who holds a PhD degree may, in many jurisdictions, use the title Doctor (often abbreviated as Dr).
The General Medical Council (GMC) website says ‘The title Doctor on its own is not a protected title as it can be an academic qualification (eg a PhD), not always linked to the practice of medicine. Therefore, a person can legitimately use the title Doctor without needing registration with us, as long as they are not practising medicine or claiming to have registration with us.’
43. From the evidence, we can see it appears that Dr S has legitimately used the title Doctor when responding to Mr M’s complaint. The information on the CCG’s website shows Dr S holds a PhD, which allows them to use the title. We have also not seen evidence to suggest Dr S was not clinically qualified to respond to Mr M’s complaint. Based on what we have seen there are no indications of a failing and we will not be looking into this complaint further.