A woman who might have had lung cancer has won an apology after she was denied money for a scan on the UK's National health Service (NHS).

by Stuart Hall

A woman who might have had lung cancer has won an apology after she was denied money for a scan on the UK's National Health Service (NHS).

Her doctors told her she needed a PET scan to find out if a lump near her lungs was malignant.

Her consultant's application for the scan to be carried out on the NHS was rejected because it was not proven whether she had lung cancer.

The patient, referred to as 'Mrs T' in the judgement, complained to the Ombudsman that Health Commission Wales (HCW), an agency of the Welsh Assembly Government, had acted unreasonably in the manner it decided not to fund a specialist scan known as a PET scan.

She explained to the Ombudsman that her doctors had identified a mass located near to her lungs which they had been unable to access using conventional techniques. Mrs T was told that in order to determine whether the mass in question was malignant it would be necessary to undertake a PET scan or perform a thoracotomy which was a major surgical procedure.

In order for patients in Wales to receive PET scans on the NHS, Health Commission Wales must first approve the funding. Mrs T's consultant applied to HCW for funding but his request was refused on the grounds that Mrs T did not have a proven case of lung cancer and therefore did not fall within their access criteria. HCW also said there were no grounds to consider Mrs T's case as exceptional.

Mrs T appealed the decision arguing that a PET scan was a much less dangerous and traumatic procedure than a thoracotomy and pointed out that a PET scan would cost the NHS considerably less than a thoracotomy with all the associated costs of major surgery, hospitalisation and convalescence.

HCW reviewed their decision but concluded that because Mrs T did not have lung cancer funding was not appropriate and they would not authorise the use of PET scan as a diagnostic tool. An appeal to an External Review Panel was also unsuccessful. In order to avoid having to undergo the thoracotomy Mrs T funded her PET scan privately. The Ombudsman considered that HCW's decision failed to take appropriate account of obviously relevant factors and was perverse in view of the evidence available to it. The decision appeared to be driven by a desire to protect HCW's own budget. The Ombudsman commented that it was absurd for a Welsh Assembly Government agency to take funding decisions which were wasteful of NHS resources overall, since those resources all came from the WAG.

He upheld Mrs T's complaint and recommended that the Welsh Assembly Government should ensure that HCW reimbursed her the cost of her PET scan and provided her with additional compensation of £500.

He recommended that the Welsh Assembly Government ensures that HCW review its PET scan policy and that it revisit the terms of reference for its external review Panels. He also recommended that the Welsh Assembly Government should urgently review the framework within which the HCW operates with a view to optimising the use of NHS resources overall.

In particular, the review should ensure that budgetary arrangements for HCW do not create perverse incentives. The Ombudsman was pleased that the Welsh Assembly Government, on seeing a draft of his report, agreed to accept these recommendations.

Health Commission Wales full report