10. Ms T complains about the ICB’s decision to decline her IFR for breast reduction surgery in March 2024. She says its decision focused too much on her BMI. She says she provided lots of evidence, to be considered as a clinical exception, but the ICB still declined to provide funding. We are sorry to hear how her large breasts impact her day-to-day life, and how she fears her quality of life will worsen if she does not have the surgery.
11. The ICB’s policy sets out in paragraph 10 it will only fund breast reduction surgery if someone meets ALL of the criteria specified below: • the woman has received a full package of supportive care from their GP such as advice on weight loss and managing pain • in cases of chest / shoulder discomfort, they have had a physiotherapy assessment • breast size results in physical symptoms that require other treatments/interventions, for example, backache where a professionally fitted bra has not helped • breast reduction planned to be 500gms or more per breast or at least four cup sizes • BMI is less than 27 and stable for at least 12 months • they have received written information to balance the risks and benefits of breast surgery.
12. The ICB’s policy also explains the IFR panel applies a two-step process to make decisions about exceptionality. The panel first decides whether the patient or their circumstances are significantly different from the general population with the condition in question. Then it decides whether the patient is likely to gain significantly more benefit from intervention than might normally be expected for patients with that condition. It says the answer to both questions must be a yes in order for clinical exceptionality to be established.
13. Ms T’s records show her health and wellbeing adviser submitted an IFR to the ICB in January 2024. They noted her BMI as 36 but said she met all other criteria. They asked the ICB to consider funding for Ms T as a clinical exception. This was due to her pain, her difficulty losing weight to meet the BMI criteria due to medication, and the impact her breasts have on her mental health.
14. The IFR panel discussed Ms T’s case in March 2024. It noted her large breasts cause her pain around her shoulders, back and neck. It also noted the psychological impact included in the request. It also said that she did not meet its criteria due to her BMI. It concluded that Ms T’s circumstances did not establish clinical exceptionality and declined the funding request.
15. Ms T’s breast size appears to meet the threshold for funding. However, her BMI is documented as 36 which is not close to the borderline of 27 set out in the criteria above. Our adviser explained this is relevant as there are more risks around surgery for people with a high BMI. They said the likelihood of complications such as poor healing, compromise of blood flow and fat necrosis (death of body tissue) within the breast can be associated with high BMI.
16. Based on the information we have seen, it appears the ICB’s decision to decline Ms T’s IFR was in line with its policy. We can see the policy clearly sets out the patient must meet all criteria for funding to be approved. In Ms T’s case her BMI does not meet the criteria.
17. We have seen evidence the ICB considered whether Ms T or her circumstances were clinically exceptional. It decided Ms T and her circumstances were not significantly different to the group of patients requesting the same treatment to determine her to be clinical exceptional. Therefore, it declined her request.
18. We cannot comment on the other patients with the same condition as Ms T, the ICB refers to. However, we can see it considered the information included in her request including the pain she experiences and the impact her breasts have on her mental health. This appears to be in line with its policy to decide if the patient’s circumstances are significantly different to others in the same situation. Therefore, we cannot see it got anything wrong when it declined her request for funding.
19. Ms T told us she has tried to lose weight for several years through different methods but has been unsuccessful due to her medication and issues she has with her mobility. Understandably, Ms T is frustrated about the ICB’s decision to decline her funding request as she told us she has a poor quality of life. She fears this will get worse without surgery, which we are sorry to hear about.
20. It is clear from what she has told us that her breasts cause her ongoing impact. Based, on the evidence we have seen, we are satisfied the ICB did not get anything wrong and followed guidance when it declined Ms T’s funding request in March 2024. We will therefore not take further action on this complaint.
21. Ms T has told us her experience has been frustrating for her, and we are sorry to hear about this. We hope this statement clearly explains our decision not to consider her complaint further.