Decision from ICS
16. We can see that Miss O does not meet the criteria for general funding and this is not disputed by either party. As such we can see that it was decided to explore exceptionality as the basis for funding in her case.
17. We established the process for applying for exceptional funding is a clinician makes an individual application based on that individual’s needs. The application is sent to the ICS panel and is reviewed and discussed on an individual basis, then the outcome is communicated. We can see Miss O’s GP applied to the ICS for skin removal surgery in August 2021.
18. In making its decision, the ICS says it used its Local Clinical Priority Policy for Cosmetic/Aesthetic Surgery.
19. This policy says, ‘Exceptionality is considered to occur when the patient:
• Is significantly different to the general population of patients with the same diagnosis/condition in question • Is more likely to benefit from this treatment/intervention than might be expected for the average patient with the diagnosis/condition’.
20. The ICS declined Miss O’s application in September saying no evidence of exceptionality has been shown. We looked at the application her GP made. We can see the contents of this are very supportive of the weight gain being because of medication and very supportive of the efforts she has taken to lose the weight.
21. While we appreciate this is very important to Miss O, the application in itself does not suggest she is very different to others who have had weight loss and would benefit from excess skin removal surgery. Similarly, the application does not support how she would benefit more than the general population of patients with the same condition.
22. The ICS declined Miss O’s appeal on 15 October 2021. It stated ‘unfortunately most mental health aspects in cases such as these are not considered exceptional according to NHS England Commissioning policy. Therefore, the panel does not consider there to be any exceptional features to merit funding according to the policy’.
23. Our clinical adviser explained the ICS policy for this type of surgery is clear and due to the high threshold, the individual that is applying needs to meet the criteria. GMC guidelines state ‘each patient should be considered and treated as in individual,’ in being able to make an individual application for funding. The ICS also has a responsibility to follow its own local policies and it has to balance both.
24. We can see Miss O provided a passionate detailed letter about the background to her putting on weight and how important it is for her to have weight loss surgery. She explained some psychological issues she deals with and how not having this surgery is a daily reminder of her past struggles.
25. However, when we look at the exceptionality test, while we appreciate fully the strength of Miss O’s feelings, we can see that many other people who have also lost a lot of weight may equally be suffering from psychological issues that would benefit from this type of surgery. Because of this, we cannot say the psychological impact in its own right meets the exceptionality test.
26. Miss O was unhappy with this decision and had a one-to-one meeting with the GP and chair of the exceptionality cases team and exceptional cases manager. She discussed her ASD, OCD and anxiety and asked if this met the criteria of an exceptional case. The ICS again confirmed she unfortunately did not meet the exceptionality criteria.
27. The ICS told Miss O that due to the broad spectrum of autism, there are less people at the severe end of the spectrum and a lot of people diagnosed with the disorder can live a ‘normal’ life. It considered Miss O’s condition does not appear to be on the severe end of the spectrum, so not making her ‘significantly different’ when compared with a similar group of patients who have the same condition.
28. The ICS also confirmed if it considered the diagnosis of autism differently to other diagnoses, it would have to approve every patient with autism, meaning it would not be seen as exceptional.
29. On 13 December 2021 the ICS directed Miss O to the medical director and chief nurse for the ICS to take an independent view, as they had no previous involvement in the case. The ICS gave them all the information it had considered so far and been given by Miss O.
30. The appeal review was on 19 January 2022. The independent staff asked the exceptional cases team if the need for repeated treatment for intertrigo (an inflammatory rash caused by skin friction) particularly under the breast area was considered during the decision to decline funding. Also, if the panel had considered this from both a physical and mental health perspective.
31. The exceptional cases team noted the section of the ICS cosmetic surgery policy where it states funding ‘may’ be considered if ‘recurrent severe intertrigo’ or the need for regular antifungal treatments or severe secondary bacterial infections. They highlighted ‘unfortunately, mild infections as described by Miss O is common with patients suffering from excessive folds of skin’. The panel explained they did not consider the degree of infection Miss O had to show exceptionality.
32. The panel did note the impact it would have on Miss O’s daily life but highlighted impact on mental health cannot be considered exceptional as many other people have similar conditions.
33. After reviewing the evidence, clinical advice and complaint responses, we are satisfied the ICS followed the correct guidelines and policies. We can see its focus was the application of its exceptionality test.
34. We can see the ICS considered her application as an individual, but the outcome was the panel found ‘no evidence of exceptionality’ and declined the funding. This is both during the individual reviews of Miss O’s consideration for the surgery and in its reasons for declining the original funding application and the appeals. Therefore, there are no signs of failings in the ICS’s decisions.
35. We are in no doubt that this has been a difficult experience for Miss O, and fully appreciate the disappointment she must have felt during this process. We recognise why Miss O wanted to understand the application process and do hope we have reassured her that the process has been looked at independently. We have explained how the application has been looked at on an individual basis by the ICS.