Humber and North Yorkshire Integrated Care Board

3. Mrs M complains that Humber and North Yorkshire Integrated Care Board (The ICB): • incorrectly decided her son, Mr M, was not eligible for CHC on 29 December 2023 • incorrectly rejected a IFR (individual funding request) for him on 7 April 2025.

4. Mrs M explains the situation has stressed the whole family, and especially Mr M. She tells us he has thoughts of wanting to end his life.

5. She is seeking the NHS to reconsider its decision and reimburse the costs she has already paid.

6. On 29 December the ICB decided Mr M does not have a primary health need and was not eligible for CHC funding.

7. On 4 April 2025 the ICB declined an IFR.

CHC decision

11. Mrs M complains the ICB incorrectly decided her son was not eligible for CHC on 29 December 2023. The ICB has upheld its decision not to award CHC funding.

12. The Health Service Commissioners Act 1993 (the law) says a person needs to make their complaint to us within a year of becoming aware of the problem. We cannot investigate complaints brought to us after one year, unless we consider there is a good reason to do so.

13. We have reviewed the timeline of events to understand if we can consider this complaint.

14. The ICB issued its decision on 29 December 2023. We consider this was Mrs M’s date of knowledge.

15. On 4 January 2024 Mrs M contacted the ICB to disagree with the decision.

16. The ICB said it called Mrs M on 6 February 2024 in response to her contact. Mrs M disputes she received this call. As we were not there, we will not be able to say exactly what happened and if this call was made or not.

17. We have seen on 6 March the ICB issued a letter to Mrs M. It confirms the appeal is closed as it has not received the requested information. The same day we have seen Mrs M requests the ICB to keep the appeal open until further notice. She explained she is waiting for a conclusion from social services.

18. We have considered if the actions of the ICB were reasonable. The ICB is unable to keep a case open ended. Mrs M explained she would be in touch with further informationIt was for Mrs M to re-engage with the appeal process once she had provided further evidence for her appeal.

19. We received a completed complaint form on 11 February 2025. This is over one year from Mrs M’s date of knowledge on 29 December 2023. We have not seen any evidence of action taken by Mrs M between 6 March 2024 until this date.

20. We have spoken with Mrs M to understand if there was any reason she could not bring her complaint to us sooner than she did.

21. Mrs M informed us she never received the letter from the ICB which said the appeal was closed. As noted above, we have seen an email from Mrs M responding to the ICB’s email which contained the closure letter. The reply from Mrs M appears to address directly the contents of the letter. On balance consider on 6 March 2024 Mrs M was aware the appeal had been closed.

22. We have not been provided with any evidence to show Mrs M followed up on her appeal. We asked Mrs M about this. Mrs M told us on 24 April 2026 while looking after her son, she had to look after her own medical health problems too. Mrs M also said the ICB did not chase her up. Mrs M forwarded us a number of emails which she says shows she did lodge an appeal. These emails are dated before the ICB’s closure letter on 6 March 2024.

23. We acknowledge looking after a dependent and dealing with her own health challenges would have impacted on her ability to complain. We are sorry to hear of her experience.

24. As noted above, we consider the ICB had informed Mrs M her appeal was closed. We would not expect the ICB to chase Mrs M at this point as it was still awaiting further information from her.

25. For this complaint to be in time, a complaint should have been made to us no later than 29 December 2025. A complaint was not made until 11 February 2026. This means the complaint is out of time.

26. We have considered Mrs M’s reasons for not contacting us sooner. This includes her own health issues and looking after a dependent. We have seen Mrs M was able to dispute the ICB’s decision within one week in January 2024. We have not seen any action was taken after 6 March 2024 until her complaint form was submitted. Given the size of the delay have not seen a justifiable reason to put the time limit to one side. We will take no further action.

IFR

27. Mrs M complains the ICB incorrectly rejected an IFR on 7 April 2025. An NHS Individual Funding Request (IFR) is a formal application submitted by a clinician to request funding for a medical treatment, drug, or service that the NHS does not routinely provide.

28. The IFR was for Mr M to receive neuro physiotherapy. Neuro physiotherapy is a specialised branch of physiotherapy that treats movement and function disorders originating from nervous system damage (brain, spinal cord, and nerves).

29. Mrs M in a letter to the ICB had explained the local authority had previously funded neuro-physiotherapy however this funding had been withdrawn in 2024.

30. We have reviewed the evidence.

31. Prior to the IFR complained about, an IFR was submitted on 31 January 2025. This was rejected as it contained a letter from Mrs M which is not permitted. A second IFR was submitted on 21 February. On the same day the ICB requested further information. The request was closed as a third IFR was submitted on 14 March. This is the IFR we are considering.

32. On 17 March, the ICB acknowledged the IFR received from Mr M’s GP. The ICB requested further information from the GP.

33. In response on 20 March, the GP requested the ICB review the previous letter sent dated 21 February 2025. In the GP’s original letter, it said Mr M has significant physical, sensory and mental health disabilities. He requires ongoing neuro physiotherapy. He had been receiving it privately, but his family have advised they are no longer able to sustain this.

34. The letter included 19 points which related to Mr M’s disabilities and how it affects him. The GP also included new information. This was the treatments received to date, the provider and a letter from the provider dated 11 March 2025.

35. The ICB’s Individual funding request policy says:

‘An individual funding request is a request received from a clinician or healthcare professional providing care to a patient where a specific treatment, intervention or procedure is requested that: • is not commissioned and not covered by existing policy; or • where there is a policy to commission an intervention, the patient does not meet clinical criteria, and; • the clinician can demonstrate exceptionality.

Exceptionality is defined as: The patient or their circumstances are significantly different from the general population of patients with the condition in question and the patient is likely to gain significantly more benefit from the intervention than might normally be expected for patients with that condition.’

36. The policy goes on to say:

‘6.4. Step one – significant difference from the general population ‘Exceptional’ in individual funding request terms means a person to whom the general rule should not apply. This implies that there is likely to be something about their clinical situation which was not considered when formulating the general rule. Very few patients have clinical circumstances which are genuinely exceptional. To justify funding for treatment for a patient which is not available to other patients, and is not part of the established care pathway, the appointed individual funding requests panel need to be satisfied that the referring clinician / healthcare professional has demonstrated that this patient’s individual clinical circumstances are clearly different to those of other patients, and that because of this difference, the general policies should not be applied. Simply put, the consideration is whether it is fair to fund this patient’s treatment when the treatment is not available to others. It should be stressed that an individual funding request is not a route to ‘have another look’ at the general rule, or to protest that the general rule is ungenerous.

6.13. Reconsideration Where a funding request is declined by the individual funding requests panel, the requesting clinician has the right to request reconsideration but only on the presentation of new clinically significant information and / or evidence.’

37. On 4 April the ICB sent a letter to Mr M’s GP. It explained Mr M’s IFR had been rejected. This was because there were two NHS provisions locally who could organise or recommend rehabilitation. It noted the provider who had been requested by Mr M’s GP in the IFR does not provide NHS services. It explained the IFR had not demonstrated exceptionality. In line with its policy, the IFR was rejected as it had not seen evidence Mr M’s condition was exceptional.

38. NHS England has its own guidance. It says:

‘When can an individual funding request be made?

An individual funding request application can be made for a treatment that is not routinely offered by the NHS: • when there is evidence of clinical exceptionality: • when there is no policy in place that gives access to an intervention for a group of patients with your clinical circumstances, that your clinician believes there are no other patients with similar clinical circumstances who might benefit from the treatment in a similar way OR

• when there is a policy in place that gives access to an intervention for a group of patients and you do not meet that policy criteria. Your clinician believes that your clinical circumstances are clearly different from other patients with the same condition who do not meet the criteria and there is a reason why you would respond differently to other patients with the same condition who do not meet the criteria – and therefore gain more clinical benefit from the treatment and, • there is evidence of clinical effectiveness of the requested treatment for your condition and, • the requested treatment will be a good use of NHS resources.’

39. We have considered the reasons for the ICB’s rejection. In line with its policy and NHSE England guidance, an IFR can be rejected If the clinician can demonstrate exceptionality. This view is supported by our clinical advisor. Our advisor agreed exceptionality was not demonstrated and there were already commissioned alternatives as set out in the ICB’s rejection letter. We have not seen a reconsideration was sought in line with 6.13 of the ICB’s policy.

40. We understand Mrs M’s frustration her son’s neuro physiotherapy was not funded. We acknowledge Mr M’s GP was supportive of him receiving neuro physiotherapy. This does not guarantee it will be funded. The ICB has explained its reason for declining the IFR. The reasons provided are in keeping with its own policy and NHS England’s guidance for declining a request. We cannot say the ICB got anything wrong in its decision making here.

1. We have carefully considered Mrs M’s complaint about Humber and North Yorkshire Integrated Care Board (the ICB). We understand how challenging the continuing healthcare process can be. We recognise this process has been stressful.

2. We consider Mrs M’s complaint about the ICB’s CHC decision is out of time for our service. We have seen no indication the ICB got anything wrong in its decision making regarding the IFR (independent funding request).