One aspect of priority setting that presents difficulties is funding requests for individual patients, particularly those based on alleged “exceptionality”.

The terms used in relation to exceptional funding are ill defined and can cause confusion.

When funding is sought for a patient outside established criteria many primary care trusts require three conditions to be met: that the patient has clinical features deviating significantly from the normal range; is likely to benefit more from treatment than other excluded patients; and that the expected benefit competes favourably with other calls on the funding available.

The notion that there has to be a funding process based on exceptionality is hardwired into NHS thinking. “Never say never!” is often cited as a legal rule and has led to commissioners feeling obliged to always leave the door open.

Another possible influence is the fact that clinicians expect to deviate from clinical protocols for patients that do not conform to the group.

“Commissioners are going to have to join forces and work together at a new level - and fast”

There has been an assumption that this should also apply to policy making.

Add a rise in legal threats, and the failure of society to engage in the rationing issue, and you get a mix that has left many a PCT wary of saying no.

Some of us would support a different approach. When developing a commissioning policy for a treatment, decision makers usually strive to consider the complexity of disease behaviour and patient responses. There is always a risk that some evidence or need is missed. When a potential deficit in its policy making comes to the PCT’s attention this should not be ignored.

But decision making at the individual level is not the way to deal with it.

An alternative is to focus debate on the case for changing policy. This is fairer as most individual funding requests actually represent groups of patients. It would also improve coherence as decisions about any group of patients should be made via the service development route.

Such an approach would reduce the workload of the individual funding request panels, leaving them to focus on true outliers. It would also enable the NHS to make more definitive statements about access. An essential counterbalance to this is that policy making would need to become more comprehensive and responsive.

In January, the government launched the NHS constitution. Sadly, the Department of Health has inadvertently embedded some of the worst of current practices into the NHS. A consequence is that the above approach might be impossible to fully implement.

It also exposes PCTs to unnecessary legal risks.

PCTs will always want the option to agree to “exceptions” but the widespread misuse of the term “exceptionality” does not serve commissioners or their communities.

There can be no single definition of the term. PCTs will have to strive for greater detail as to how they assess different types of requests. The way forward is not clear but commissioners are going to have to join forces and work together at a new level - and fast.