CCG did not explain its decision not to fund surgery

What happened

The CCG decided not to authorise funding for surgery for Mrs G. It said that Mrs G's body mass index raised concerns about her safety if surgery went ahead.

Mrs G argued that there were significant clinical reasons for the surgery that overrode the potential dangers which the CCG had not taken into account. She said that the reasons made her case 'exceptional'. Exceptionality is a requirement if funding is to be awarded.

Mrs G appealed against the CCG's decision. The CCG re–examined the facts of the case but reached the same decision.

What we found

We partly upheld this complaint. When we look at individual funding request cases we will not, as a rule, overturn the decision on eligibility made by the NHS.

In this case, the individual funding request panel based its judgment on clinical advice. The panel had access to the clinical facts and made its decision accordingly.

However, we were concerned about the explanation the CCG gave Mrs G, through her GP, to support its decision. This did not mention why the CCG considered that Mrs G was not exceptional, meaning that Mrs G did not have a full explanation of the decision not to award funding.

Putting it right

The CCG left it open to Mrs G to submit a further application for funding. Therefore, we did not believe that Mrs G had suffered any injustice because of the shortcomings in the explanation she received.