PCT failed to properly consider funding request

What happened

The PCT's individual funding policy gave applicants two possible routes. The first was for patients with rare medical conditions for which the PCT had no commissioning policy. In these cases, the PCT was entitled to approve requests for funding if there was evidence that the treatment was likely to be clinically effective as well as cost effective.

The second route was for patients who had a medical condition for which the PCT had a commissioning policy, but where the requested treatment had not been agreed for funding under that policy. In these cases, in addition to satisfying the clinical and cost effectiveness tests, the patient would have to also prove that they were 'exceptional'. In other words, that they were significantly different to other people in the general population with the condition in question, and were likely to get significantly more benefit from the requested treatment than might normally be expected.

The PCT declined Mr J's individual funding request on the basis that it did not think that there were any exceptional circumstances in his case.

What we found

The PCT should have recognised that Mr J was suffering from a rare condition (affecting around 1 in 50,000 people) for which it had no commissioning policy.

It was unfair to expect Mr J to prove that he was an atypical patient or that he presented an exception to a commissioning policy that did not exist.

Putting it right

We recommended that the PCT's successor commissioning organisation, Coastal West Sussex Clinical Commissioning Group, acknowledge and apologise for the failings and injustice, pay Mr J £500, and keep to a commitment it made to us to fund the liposuction.