Download Adenoidectomy with Grommets Application Form

Procedure funded subject to Audit
Application form: Myringotomy/Grommet Insertion for otitis media with effusion in
Children and Adjuvant Adenoidectomy
Name of GP/Clinician requesting funding
Practice Name/Trust of applicant
Contact telephone number
Contact NHS.Net email address
Patients NHS Number
Consultants name (if known)
For onward referral
Hospital/ NHS Trust name (if known)
For onward referral
This procedure is funded subject to audit for Berkshire West patient’s that fully meet the criteria specified in the
policy statement for surgical management of otitis media with effusion.
This form is to be completed by the GP/Consultant for Berkshire West patient’s when applying for funding if the
patient does not meet the criterial but there are exceptional health needs. The exceptional health needs must be
clearly detailed on the form and application.
Email the completed form and papers to the IFR service at: [email protected] for consideration.
Please note that unless the patient fully meets the criteria or there are exceptional health needs clearly demonstrated in the form which are
deemed acceptable by the panel, it is unlikely that funding will be approved.
Patient/Guardian Consent By submitting this request you are confirming that you have fully explained to the patient the proposed
treatment and they have consented to you raising this request on their behalf.
Is the patient/guardian aware of this referral and the contents of this form and supporting documents?
YES
NO
Please complete the following sections in full. Incomplete applications will not be considered and will
be returned.
Clinical Criteria required for consideration for
treatment
Please tick and add details where requested
Grommet Criteria
1. Indicate which ear it is proposed to treat.
2. Has the patient had persistent bilateral otitis
media with effusion (OME), with a hearing loss of
at least 25 dBHL or more?
Please provide details
3. Has there been a 3 month period of watchful
within secondary care
4. Has the patient’s hearing been re-tested at the
end of this time period?
Right
☐
Left
☐
YES ☐
NO ☐
YES ☐
NO ☐
YES ☐
NO ☐
Bilateral ☐
Exceptional health needs, please provide clinical details:
South, Central and West Commissioning Support Unit July 2016
PLEASE TURN OVER
Grommet insertion for other Indications
5. Management of OME in children with Down’s
Syndrome:
YES ☐
NO ☐
Have hearing aids been offered to the child with
Down’s Syndrome and OME with hearing loss?
Please specify or please state N/A
6. Management of OME in children with Cleft
Palette:
 Insertion of ventilation tubes at primary
closure of the cleft palate should be
performed only after careful otological and
audiological assessment.
 Insertion of ventilation tubes should be
offered as an alternative to hearing aids in
children with cleft palate who have OME
and persistent hearing loss.
Please provide evidence or state N/A
Adjuvant Adenoidectomy
1.
Has the patient had persistent and/or frequent
upper respiratory tract symptoms?
YES ☐
NO ☐
YES ☐
NO ☐
Please provide specific details or state N/A
2. Strong suspicion of sleep apnoea?
Please provide specific details or state N/A
Exceptional health needs, please provide clinical details:
SIGNATURE OF CLINICIAN……………………………………..Date:…………………………….
Exceptional Status (what makes the individual sufficiently different from the ‘usual’ in policy terms). Central to consideration of individual requests
for funding is the concept of the case being exceptional.
In order for funding to be agreed there must be unusual or unique clinical factors about the patient that suggest that they are:

Significantly different to the general population of patients with the condition in question
and

likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition.
However:

The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception.

If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by
definition, exceptional.

Social value judgements (the 'worth’ of patients) are not relevant to the consideration of exceptional status but there may rarely be
exceptional circumstances where benefits may go beyond the patient (e.g. as a carer) in respect of social or health related
benefits for others.
Please email the completed form to [email protected] for consideration.
South, Central and West Commissioning Support Unit July 2016