Irwin Mitchell's public law solicitors acted for a woman regarding a challenge to NHS Gloucestershire Clinical Commissioning Group’s (CCG) decision to decline funding for our client’s abdominal reconstruction.
Following an abdominal hernia, our client - Hazel - needed abdominal surgery consisting of an incisional hernia repair and an abdominal reconstruction. The CCG granted funding for an incisional hernia repair, but declined to fund an abdominal reconstruction, as they decided it was a primarily cosmetic procedure that wouldn't benefit any non-cosmetic symptoms.
The decision was sent to an independent appeal panel in January 2012, but the original decision was upheld. A complaint was then made to the Parliamentary and Health Service Ombudsman in March 2012, but the original decision was again upheld. Our client continued to write to the CCG to try and obtain funding for both branches of the surgery, but was unsuccessful.
We wrote to the CCG on 13 August 2013 stating that the consultant surgeon had confirmed that the last part of the incisional hernia operation would be essentially similar to an abdominoplasty. He didn't consider it to be a separate part of the abdominal wall reconstruction and said that the repair and the reconstruction should therefore be carried out together as one single procedure.
The consultant also stated that he wouldn't recommend that two separate procedures be carried out, due to the associated health risks to our client in doing so.
In our correspondence to the CCG we also highlighted that our client’s GP had already expressed to the CCG that the reconstruction procedure itself should not be defined as cosmetic, as it is simply an extension of the incisional hernia repair surgery.
The CCG had previously been aware of both these clinicians’ opinions. However, they failed to provide a substantial response to our client in relation to these points, and simply repeated the history of the application and appeals. We highlighted the CCG’s failure to provide an adequate response in this matter, and requested a reconsideration of their original decision.
Following our initial letter, the CCG sought additional clinical advice on the matter. They confirmed that, provided the procedure was carried out as a single operation at a cost equivalent to a certain NHS tariff, they would approve the funding for the incisional hernia repair, including the elements of the abdominal wall reconstruction. Our client was then able to list herself for the surgery without any additional cost to herself.
Our client commented: "If Irwin Mitchell hadn’t stepped in I don’t know who would. I would never have made any headway with the CCG without them."
For expert advice on matters relating to healthcare law, please contact Mathieu Culverhouse of Irwin Mitchell's public law team on 0370 1500 100 or complete our enquiry form.
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