Issues over funding of specific medical treatments or drugs
The National Institute for Health and Clinical Excellence (NICE) is an independent organisation which was set up by the Government in 1999.
NICE decides which drugs and treatments are available on the NHS in England and Wales. Some of the functions described below are likely to change as a result of NHS reforms proposed for 2012-14.
In making the decision whether to approve a drug for prescription on the NHS, NICE uses a formula called the “Quality-adjusted Life Year” (QALY). This gives each treatment a score for the benefit it gives in quality and length of life and is then compared to cost.
Officials also seek guidance from a range of sources, including NHS advisers NICE, local doctors and the government in the form of national service frameworks.
What are the options if a drug has not received NICE approval?
When treatment is not approved by NICE, the treatment is available to a patient privately or at the discretion of their local Primary Care Trust (PCT).
If the patient’s doctor agrees that the treatment would help, the patient can apply to the PCT for 'exceptional funding' (money which the PCT keeps aside for these claims). People do sometimes succeed in getting treatments funded this way.
However, each PCT has a budget to spend on varying needs of patients and the PCT may find it difficult to justify spending money on such a drug when others have been recommended. In reality, there is a clear difference in the treatments that various Trusts are prepared to fund.
In addition, funding may be available through the Government's new 'emergency cancer drug fund'. This applies until the £200 million cancer drugs fund starts up in April 2011. The fund aims to cover treatment costs for cancer patients for drugs that have not been approved by NICE. The patient should go through their own specialist, who will make an application to their regional Strategic Health Authority.
Can a decision of a PCT be challenged?
Decisions of the PCT can be challenged through legal action.
What happens if NICE guidance is not followed?
Unfortunately, the approval of NICE does guarantee that the treatment will be used. If a drug is approved by NICE and a patient is refused it, the patient should consider if this is the best treatment at this particular time and if there are any reasons why they shouldn’t have the treatment, for example side effects.
The patient should then follow the NHS complaint process. If the refusal is maintained the next point of contact is the Care Quality Commission who can investigate the complaint. A decision by the PCT to refuse NICE approved treatments can also be challenged with legal action.
How we can help?
We have significant experience of advising patients in these difficult situations.
For free and expert advice on making a medical negligence claim click here or call us free on 0800 0382 382. We are available to take your call twenty four hours a day, seven days a week.
If you want to provide some details to us in advance, why not let us assess your claim.
