NHS Dorset

4. Miss C complains about the ICB’s decision to refuse her Individual Funding Request (IFR) application to receive funding to cover the costs of dental implant from a private dentist.

5. Miss C says she has been receiving specialist dental treatment for 20 years and due to a change in the criteria she no longer has the funding to continue the treatment at the Trust. Mrs C has approached several NHS dentists who are unable to treat and only option now available to her is private treatment. Her existing dental issues have affected her physically and mentally.

6. As an outcome, she wants the ICB to reconsider its decision.

7. Miss C has had longstanding problems with her teeth. In February 2023, her dentist submitted an IFR on Miss C’s behalf for funding to pay for dental implants. An IFR is an application to fund an NHS treatment that is not normally offered to patients. It is submitted by a clinician when they believe a patient has exceptional circumstances that make them different from others with the same condition.

8. The ICB considered the application in October and declined it. It communicated the decision to Miss C’s dentist in November.

9. In July 2024, Miss C’s GP wrote to the ICB and asked it to reconsider its decision. The ICB responded in August 2024 upholding its original decision and recommended that the GP refer to a dentist for a specialist opinion within the hospital services for restorative opinion for advice and treatment planning.

12. Miss C told us she has complex dental health issues, a damaged jaw, difficulty chewing, and muscle wastage, for which she was receiving treatment at the dental hospital (the Trust). In 2022, a consultant informed Miss C that it could not continue her treatment at the Trust due to a change in funding and that she would need to make an individual funding request application.

13. The ICB will only fund restorative dentistry if someone meets ALL of the criteria specified below: • exceptional clinical circumstances which can be established in one of two ways • there is an NHS England policy or National Institute of Clinical Excellence (NICE) guidance that covers the patient’s condition, but the patient’s clinical situation is so different from the typical patient that they likely gain meaningful benefit from treatment, OR • there is no relevant NHS England policy or NICE guidance covering the patient’s condition or combination of conditions and the patient’s clinical presentation is so unusual that they cannot reasonably be grouped with any other defined patient population for whom a service could be developed, AND • the treatment is likely to work for this patient, AND • the treatment represents good use of NHS resources.

14. The ICB’s policy, explained the IFR panel applies a process to decide 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.

15. The ICB’s policy paragraph 11.11 does state that where a patient has exhausted all NHS treatment options for a particular condition that does not, in itself, mean that they are clinically exceptional.

16. In February 2023, Miss C’s dentist completed an IFR for her to receive dental implants, restoration, crown, filling and denture. The application included evidence setting out the cost of the private treatment. Her application did not include clinical evidence of the treatment she had received on the NHS and which worked and which did not.

17. The IFR panel discussed Miss C’s case in October 2023. It noted the panel considered Miss C’s IFR application included no information as to how she met the exceptional criteria, that she was non-compliant on care and she had not controlled her dental disease and oral hygiene. It concluded that Miss C’s circumstances did not establish clinical exceptionality and declined the funding request. The decision was communicated to the dentist in November 2023.

18. In July 2024, the ICB received a review request from Miss C’s GP and her MP to review her IFR application. Within the GP’s email, they explained ‘Miss C had a mal-aligned jaw and had hospital dental treatment on three occasions over a 20-year period. She had seen a private dentist who suggested implants, but she cannot afford it. She had difficulty chewing and is restricted on the foods she can eat’. The appeal did not include any clinical evidence of the treatment Miss C had received to date.

19. The IFR panel discussed Miss C’s case and concluded that Miss C’s circumstances did not establish clinical exceptionality and declined the funding request.

20. The IFR panel communicated the decision to Miss C’s GP in August 2024. It advised Miss C’s GP to make a referral to a hospital-based specialist dentist team. The purpose of the referral was to obtain expert clinical opinion and to develop an appropriate restorative treatment plan for Miss C.

21. Based on the information we have seen, it appears the ICB’s decision to decline Miss C’s IFR was in line with its policy. We can see the policy clearly sets out that the patient must meet all criteria for funding to be approved. In Miss C’s case, she had not provided any clinical evidence to show how she met the criteria.

22. Miss C told us she had seen several NHS dentists after receiving the initial decision, but we have seen no evidence that she informed the ICB of this or had sent supporting clinical evidence. It is clear that Miss C’s dental issues have caused her ongoing impact. From the evidence we have seen, we are satisfied that the ICB did not get anything wrong and followed the guidance when it declined Miss C’s funding request in August 2024. We will therefore not take further action on this complaint.

23. Miss C 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.

1. We have carefully considered Miss C’s complaint about NHS Dorset Integrated Care Board (the ICB). We are sorry to hear about the events that led to Mrs C to complain. We are sorry to hear that her existing dental problems have affected her physically and mentally.

2. We have looked at the evidence Miss C and the ICB provided. We have seen the ICB followed its policy when it made its decision. We have seen no evidence that anything went wrong. Therefore, we will not be taking further action on this complaint.

3. We will explain our decision in more detail below.