South East London Integrated Care Board

4. Ms A complains the South East London Integrated Care Board declined her appeal for appropriate outpatient mental health therapy in March 2022 as it said she needed a comprehensive assessment. However, she says when she completed the required assessment in February 2023, the ICB did not acknowledge the assessment or explain why it was not adequate to provide the therapy she needs.

5. She says the last six years have been extremely damaging for her and her family as she feels she has been denied the therapy she needs, and this has been distressing. She says that the ICB is not being truthful or clear in its responses, and its lack of explanation causes her confusion about what she needs to do to get the treatment she needs.

6. She says this has led to a decline in her physical health, she has not been able to lead a normal life, cannot take part in everyday events, has been unable to work, unable to get to appointments for her physical health, and has lost out on five years of being able to participate fully in finding a partner or work prospects. She says the lack of appropriate therapy has also impacted her mother’s life as she stays at home to care for her. Ms A wants an apology from the ICB.

7. This very brief background is only intended to place the key events in context, not to provide a full, chronological account of everything that happened.

8. Ms A was approximately 36 years old at the time of events with a past medical history that includes diabetes. In September 2021, the ICB asked Ms A’s GP to submit an individual funding request (IFR) so it could consider funding for mental health therapy for her. An IFR is a request for funding for a treatment or service that is not routinely commissioned by the NHS.

9. The ICB reviewed the request in November and declined the request for funding as it needed a clinical assessment of Ms A’s current clinical needs. She had an assessment at a service under the ICB in February 2023. The ICB reviewed this in April and declined the request for funding as it did not consider the service had assessed Ms A’s current needs.

12. Before we decide if we should conduct a detailed investigation of 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 have not found any indications that something has gone wrong.

13. Ms A is understandably concerned the ICB has not acknowledged or explained why an assessment from February 2023, was not adequate to fund the mental health therapy she needs. She told us the ICB will not tell her why her funding has been declined or what she needs to do to get her therapy funded.

14. We were sorry to hear Ms A’s concerns about how the ICB managed her request for funding. From what she told us, her experience has massively impacted her life, and she is yet to receive the mental health therapy she needs.

15. The ICB’s ethical decision-making framework policy says it is committed to evidence-based healthcare and decisions should therefore be made based on a reasonable evaluation of the available evidence of clinical effectiveness. Those involved in decision-making have an obligation to seek out the best evidence of clinical effectiveness to inform their decisions.

16. The ICB’s TRP policy explains the appeal process. It says it enables applicants to appeal against the decision made by the IFR panel. It goes on to say in instances where the patient wishes to appeal the decision of the Panel and they show additional relevant information, their request will be submitted for further review and consideration at the next available Panel. In the event the review decision is not accepted, it will be escalated to the senior responsible officer (SRO) for mental health for the final determination.

17. From the information we have seen, it appears that Ms A’s psychologist originally submitted an IFR for mental health therapy at a specific clinic in approximately 2018. The ICB reviewed this request and offered her therapy at an alternative clinic. Unfortunately, Ms A did not feel this clinic would be able to support her diabetic condition.

18. Unfortunately, it is not clear from the medical records what happened following this. However, we can see that the ICB asked Ms A’s GP to submit another IFR for it to review in September 2021, which the GP did in October. The ICB reviewed the funding request in November. It explained that it could not decide if treatment at Ms A’s preferred clinic was appropriate as she had been out of local treatment for more than three years. It decided that she needed a recent clinical assessment of her needs before it could approve funding for her mental health therapy. It offered her an assessment at one of the mental health providers under the ICB.

19. Ms A appealed this decision in March 2022, and after a review, the ICB upheld its previous decision that she needed an assessment of her needs from a service under the ICB that had access to her historical clinical records.

20. When Ms A asked for clarification of the decision in August, the ICB reviewed its decision in September. It explained that the Panel still needed to understand Ms A’s current needs and after she had undergone an assessment, it could consider any support and adjustments she may need to access therapy.

21. We can see that each time Ms A as appealed the ICB’s decision, it considered each appeal and reviewed it at Panel, in line with its TRP policy. We have also seen evidence that the ICB escalated Ms A’s appeals to the ICB’s SRO which is also in line with its appeals process.

22. In December, Ms A accepted the ICB’s suggested assessment of her needs, and she was reviewed by one of the mental health providers under the ICB in February 2023. This hospital explained that its clinic would not be able to offer suitable therapy for her needs.

23. The ICB reviewed this assessment in April and decided that the clinic had not carried out a clinical assessment of her current needs but instead given an opinion that it did not think it could meet them. The ICB said it would not proceed to fund treatment until Ms A has had a clinical assessment and the clinician assessing her will need to access her history and clinical records. It offered Ms A the option to be assessed by another specialist service under the ICB with clinicians she had not previously had contact with. We cannot see any evidence that Ms A has had this assessment.

24. Based on what we have seen, it appears the ICB declined Ms A’s IFR application in 2021 as she needed an up-to-date assessment of her clinical needs to decide if treatment at her preferred clinic would be suitable for her. Unfortunately, the assessment by another hospital in February 2023 appears to be an opinion that it cannot meet Ms A’s needs rather than an assessment of what her needs are. Our lead clinician explained that ICBs cannot fund therapies without good reason, and it appears an assessment of Ms A’s needs remains outstanding.

25. Therefore, it appears the ICB followed its ethical decision-making framework policy when it declined Ms A’s IFR in 2021 as it has an obligation to seek out the best evidence of clinical effectiveness to inform its decision on if it should approve funding. As this assessment is still outstanding, it has not been able to make this decision. The ICB told us its offer of an up-to-date assessment of Ms A’s needs, is still open to her if she wishes to pursue it.

26. Based on the evidence we have considered, we have not seen any indications that the ICB got anything wrong when it originally requested Ms A had an assessment of her current needs or when it decided the assessment from February 2023 did not give it the information it needed to make a decision on her funding request. It appears it followed its own policy on ensuring it has the best available evidence before it can agree to fund the therapy.

27. Therefore, based on this and the advice from our lead clinician, we will decline to investigate this complaint as it appears the ICB followed relevant guidelines. It is understandable that this will disappointing for Ms A, and we are sorry that her concerns continue to cause her ongoing distress. We hope our report and explanations go some way to clarify any information she was unsure about.

1. We have carefully considered Ms A’s complaint about the South East London Integrated Care Board (the ICB). We were sorry to hear her concerns about how the ICB considered an assessment for mental health therapy in February 2023. From what she told us, it is clear that this has been a very distressing experience for Ms A and her concerns about how the ICB managed her care continue to impact both her physical and mental wellbeing.

2. Based on the information we have considered, we have seen no indications that anything went wrong. We have seen that the ICB followed relevant guidelines when it managed Ms A’s request for mental health therapy at a preferred clinic. We have therefore decided to take no further action for this reason.

3. We recognise how important this complaint is to Ms A, and we do not wish to underestimate her experience. We would like to take this opportunity to thank her for bringing her complaint to our attention. We hope our explanations below show how we have considered this complaint and gives her some reassurances that the ICB followed relevant guidelines.