Bath and North East Somerset Swindon and Wiltshire Clinical Commissioning Group

3. Mrs H complains about the CCG’s decision not to fund breast surgery in January 2021. Mrs H says when she initially had surgery in 2005, she was told implant replacements would be required in about ten years, and this would be funded by the NHS. Mrs H said when she returned to the hospital for the replacement surgery in 2020/21, the CCG declined to fund the treatment, as its funding policy had changed.

4. As a result, Mrs H says she suffers pain and discomfort from not having the replacement surgery. She has been told she needs to fund this herself privately, which will have a significant financial impact on her.

5. By bringing the complaint to us, Mrs H is seeking a change in policy so that her surgery is funded through the NHS. Alternatively, she would like to receive compensation to have surgery at a private hospital.

6. In 2005 Mrs H had surgery on her breast and was told at that time the follow up surgery would be funded by the NHS. Mrs H now requires the follow up surgery on her breast, but the CCG is declining to fund the treatment as its funding policy has changed.

7. The CCG declined Mrs H’s funding requests on three occasions. In its final letter, dated 13 January 2021, the CCG said it would not consider the case again as it had declined it three times.

Failure to provide follow up breast surgery

10. 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.

11. Mrs H had NHS funded breast surgery in 2005, and says she was told she would require the implants to be replaced and a ‘lift’ in ten years. At that time, she says she was told this further surgery would be funded by the NHS. When she enquired about having the further surgery, around 2018, she was told it was no longer funded by the NHS and she would need to fund it herself, privately. With the support of her surgeon, Mrs H applied to the CCG for ‘exceptional funding’ to cover the implant replacement and ‘lift’.

12. When a CCG receives an Individual or exceptional Funding request (IFR), it first looks to see whether the request for funding is covered by a specific policy, and if it is, whether the patient meets the criteria of that policy. If an IFR does not meet the criteria, or if there is no relevant policy, the CCG will then look to see if there are ‘exceptional clinical circumstances’. It is often very difficult to demonstrate how somebody meets the exceptionality criteria. This is intentional, as CCGs healthcare budgets are based on following their usual funding policies, and so exceptions should be granted very rarely.

13. The CCG rejected Mrs H’s application for exceptional funding three times, on 9 April 2018, 10 February 2020, and 13 January 2021. In its letter, 9 April 2018, the CCG explained that her applications did not meet its criteria for exceptional funding and explained it does not normally fund cosmetic breast surgery. The CCG explained its role was to improve the health of the entire population it covers. This means it bases its decisions on what to fund on ‘national best practice and clinical evidence’. It explained this means some treatments may not be funded.

14. In its letter dated 10 February 2020, the CCG provided its definition of exceptionality and again explained it does not normally fund cosmetic breast surgery. It also said it did not have sufficient information to demonstrate Mrs H’s exceptionality. In its letter, dated 13 January 2021, the CCG said it would not approve funding for a ‘reduction’, but agreed to fund removal of the left implant as it was causing Mrs H pain.

15. The CCG’s policy ‘what we do and don’t fund’ covers breast surgery, for which exceptional funding is required. This policy says the CCG will not normally fund cosmetic procedures in the absence of disease, significant congenital deformity, and where this is causing impaired ability to perform daily activities. The section ‘Breast surgery – cosmetic’ sets out procedures classed as ‘cosmetic’, which includes mastopexy (breast lift) and breast surgery due to asymmetry. The policy also says psychological distress alone will not normally be accepted as a reason to fund surgery.

16. We have considered whether the CCG’s policy reflects national policy. The NHS information ‘Is cosmetic surgery available on the NHS?’, says this type of surgery, including breast implants and breast reduction, will not be routinely funded by the NHS. We are satisfied the CCG’s funding policy for breast surgery reflects this.

17. We have seen no evidence from Mrs H to demonstrate any of the conditions listed in paragraph 15 above apply to her. The CCG considered Mrs H’s circumstances and reached a decision, which is in line with its funding policy. The CCG has demonstrated it has considered Mrs H’s request for funding under the ‘exceptional’ funding policy for cosmetic surgery and has explained why she does not meet the definition of exceptionality.

18. We appreciate Mrs H feels the CCG should fund the treatment, as it is linked to surgery she had in 2005. The CCG has reached its decision in line with its funding policy for breast surgery, and we have seen no indications it has not properly considered the information Mrs H provided in her funding requests. As we have seen nothing to indicate the CCG has got things wrong, we will not consider this complaint further.

1. We have carefully considered Mrs H’s complaint about Bath and North East Somerset, Swindon and Wiltshire Clinical Commissioning Group (the CCG). We have decided not to consider this complaint further as we have seen no indication the CCG has done anything that would be considered as maladministration.

2. We are very sorry to hear about the circumstances that led Mrs H to approach us. We do not underestimate the difficulties she has faced, and appreciate the distress, upset, and pain Mrs H described as a result of not having the surgery she wants.