Download Funding Request Form - North West Commissioning Support Unit

GM EUR FUNDING REQUEST FORM
Facet Joint Injections for Back Pain
The Individual Funding Request Case Panel
Dealing equitably and appropriately with individual funding requests (IFRs) or exceptionality claims
requires CCG decisions on an individual to be governed by the same principles as those that are applied
to others with that condition and to the larger the population. Considerations of cost effectiveness rather
than solely clinical effectiveness, the nature of the health gain and the quality of the evidence supporting
the treatment are applied when a CCG considers funding a treatment for a group of patients and so
these factors will similarly be considered when a treatment is requested for an individual.
The standard proforma
The use of a standardised form is an attempt to ensure that the Panel receives only those applications
which are:
 appropriate
 contain adequate information; and
 address all relevant factors
Before referring a patient please check the referral criteria and ensure that all the appropriate information
is provide otherwise a decision will be made on the basis of the information provided. It is important,
therefore, that the form is as fully completed as possible before submission to the CCG. An incomplete
form will, at best, delay the funding request process through additional information having to be sought
and, at worst, may mean the request being turned down because all of the relevant details have not
been presented to the Panel. The Panel must base its decision on the information supplied by the
requesting clinician and it is therefore vital that all relevant details are included on the proforma.
Please note: It is the responsibility of the requesting clinician (together with the patient) to supply the
information / evidence required to support the request – that the treatment requested is clinically and
cost-effective and, where the case relates to exceptionality, that the patient’s case differs significantly
from others with the same condition and stage of disease.
Further information can be obtained from your clinical systems (where this has been rolled out) or via the
relevant link below:
Links to EUR page on CCG websites
Bolton CCG
Bury CCG
Heywood, Middleton & Rochdale CCG
Manchester CCG
Oldham CCG
Salford CCG
Stockport CCG
Tameside & Glossop CCG
Trafford CCG
Wigan Borough CCG
Document1
1 of 8
When should this form be used?
The purpose of the IFR process is to provide a mechanism for considering the needs of individual
patients whose clinical circumstances might mean that an existing care pathway or treatment regime is
unsuitable for them or make them an ‘exception’ to CCG commissioning policies. For more details
please refer to the GM EUR Operational Policy.
NOTE: The Panel will only consider clinical factors in considering individual funding requests.
Social factors will not routinely be considered.
When should this form not be used?
If a patient's clinical condition matches the 'accepted indications' for a treatment that is not currently
funded, the request, by definition, is not for an individual but applies to a cohort of patients (now and in
the future, however small) and will not be considered by the Panel.
Equally, the IFR process should not be used where the intention is to introduce a new intervention for a
definable group of patients (however small). You should forward such requests for consideration by the
CCG commissioners, usually via the development of a business case for the CCG to consider as part of
its annual commissioning round.
Instructions for completion
1. This form should be completed electronically on screen using Word.
2. When complete, save the document to your own file folders.
3. Please ensure that any additional information that you wish to be considered alongside the proforma
is included as either hyperlinks within the proforma or sent by e-mail as additional documents.
4. Clinical papers cited as references should be provided in full; abstracts, hyperlinks to abstracts or
hyperlinks to papers only available by subscription to Journals are not acceptable.
5. Please send the completed proforma to [email protected] [secure NHSmail address]
6. If you would like further information regarding the CCG’s IFR processes or advice on completing this
form, please contact:
Effective Use of Resources (EUR) Team
Greater Manchester Shared Services
Ellen House
Waddington Street
Oldham
OL9 6EE
Tel: 0161 212 6250
NOTE: We would prefer to receive this form electronically; please only send by post in
exceptional circumstances.
Document1
2 of 8
GM EUR Funding Request Form
Facet Joint Injections for Back Pain
New Patients
Facet joint injections are commissioned for patients who meet the following criteria:
 The back pain has been present for more than 1 year and all chronic pain management pathways have failed.
AND
 There is no other treatment option available for the patient
OR
 Alternative treatments such as analgesic medication are intolerable or produce undesirable side effects
OR

The patient has demonstrated failure to respond to, or had a loss of response to other treatment options
OR

Other treatment options are contraindicated and this is clearly documented
Wherever possible patients should be encouraged to:

participate in mobilisation or rehabilitation therapy

take effective pain relief medication

where indicated (and where it is available) be referred for weight management support
If new patients gain relief from facet joint injections and are suitable for radiofrequency denervation and have a
positive response to facet joint injections they should be referred for radiofrequency denervation.
Diagnostic Injections
Facet joint injections are commissioned by Individual Prior Approval for patients being assessed for radiofrequency
denervation in line with the Radiofrequency Denervation Policy only, any other diagnostic use of facet joint
injections will require an Individual Funding Request application. Patients given prior approval for two diagnostic
injections will be considered to have prior approval for radiofrequency denervation if the response to both injections
is positive. (NOTE: If the diagnosis is clear and one injections is effective then patients can be referred for
Radiofrequency Denervation - see Radiofrequency Denervation Policy for details).
Current Patients
Facet joint injections will continue to be commissioned for existing patients via monitored approval provided that
there is a demonstrable improvement in quality of life measures following each treatment, this should be assessed
using a validated research tool.
Treatments should only continue where alternative treatments such as analgesic medication are intolerable or
produce undesirable side effects, such as unsteadiness in the elderly.
If treatment with facet joint injections is successful on more than two occasions suitable individuals should be
referred for radiofrequency denervation if facet joint injections are to continue then the individual should be
considered unsuitable for radiofrequency denervation for reasons including but not limited to:

The presence of comorbidities that contraindicate radiofrequency denervation

Access or other anticipated mechanical difficulties in the delivery of radiofrequency denervation

Inability of the patient to adopt or maintain the required position for the safe delivery of radiofrequency
denervation
Treatment is limited to no more than 2 injections a year the interval between injections should be at least 6 months
but ideally be no more frequent than 8-12 month intervals.
Facet joint injections should not be administered if:

There is evidence of a local or systemic infection

The patient is receiving substantial therapeutic or constitutional anticoagulation

The patient is unwilling or is demonstrating a lack of cooperation
Document1
3 of 8
Application details
1
Application for
Click here to enter text.
e.g. drug / referral / intervention and
whether it is for a procedure / new
treatment / second opinion etc.
(short description only; a more
comprehensive description will be
required later)
2
3
Date of application
Application to
Click here to enter a date.
Click here to enter text.
(Commissioning CCG name)
Referring clinician details
4
Clinician name
Click here to enter text.
Please include contact details below
in case of queries etc.
5
6
Job Title
Address
Click here to enter text.
Click here to enter text.
7
Telephone number
8
Email address
Patient details
9
Name
10 Postcode
11 Date of birth
12 GP name
13 GP address
Click here to enter text.
Click here to enter text.
14 NHS No.
Supporting information
15 New patients only
Click here to enter text.
Has the back pain been
present for more than 1
year and all chronic pain
management pathways
have failed?
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Click here to enter text.
Select Yes or No
IF YES, please give the date of the onset of pain and details of pathway
previously followed and response.
IF NO, please provide details of why the request has been submitted in the box
below. Please also provide a statement detailing how the patient is clinically
exceptional in box 23.
Click here to enter information
Document1
4 of 8
AND
Are there any other
treatment options available
for the patient?
Select Yes or No
IF YES, please state why the patient hasn’t tried the alternative options.
Click here to enter information if YES
OR
Where alternative
treatments have been tried
(such as analgesics) are
these intolerable or
produce undesirable side
effects?
Select Yes or No
IF YES, please give details below.
Click here to enter information if YES
OR
Has the patient not
responded to or had a loss
of response to other
treatment options?
Select Yes or No
IF YES, please give details below.
Click here to enter information if YES
OR
Are other treatment options
contraindicated?
Select Yes or No
IF YES, please give details below.
Click here to enter information if YES
16
Current patients only
Is there evidence of
improvement in the
patient’s quality of life
following each previous
injection, using a validated
research tool?
Select Yes or No
IF YES, please give details below including the name of the tool used for
assessment.
Click here to enter information if YES
AND
Are alternative treatments
such as analgesic
medication intolerable to
the patient or produce
undesirable side effects,
such as unsteadiness in
the elderly?
Document1
Select Yes or No
IF YES, please provide more details on the medications tried, the effects and the
response.
Click here to enter information if YES
5 of 8
AND
Select Yes or No
Has the patient had more
than 2 successful facet
joint injections?
IF YES, why is the patient unsuitable for radiofrequency denervation?
Click here to enter information if YES
(NOTE: All patients who are suitable
for
radiofrequency
denervation
should be referred after two
successful facet joint injections)
Examples of unsuitability could
include (but is not limited to):
 The presence of comorbidities
that contraindicate radiofrequency
denervation
 Access or other anticipated
mechanical difficulties in the
delivery
of
radiofrequency
denervation
 Inability of the patient to adopt or
maintain the required position for
the
safe
delivery
of
radiofrequency denervation
AND
Click here to enter information
How many injections has
the patient had in the
previous 12 months and
what was the interval
between each injection?
Please list dates of injections and
interval between each.
17
Diagnostic injections only
Is the purpose of the facet
joint injection to assess the
patient’s suitability for
radiofrequency denervation
in line with the Greater
Manchester
Radiofrequency
Denervation Policy?
Medical history
18 Any other relevant past
medical history
Select Yes or No
IF NO, please provide further details in the box below. Please also include a
statement detailing how the patient is clinically exceptional in the box 23.
Click here to enter information if NO
Click here to enter text.
Please detail any other relevant
medical conditions that may
influence decisions regarding the
treatment being proposed. This may
also include reasons that certain
treatments cannot be given.
Document1
6 of 8
Details of treatment requested
19 Who will provide this
treatment / intervention?
Click here to enter text.
Referrer or other provider?
20
What is the cost of the
treatment?
Click here to enter text.
Known / estimated total cost if time
limited / one off OR known /
estimated annual cost if on-going.
21
Has the patient been
informed of any additional
clinical risks involved with
the proposed treatment?
Click here to enter text.
Please outline risks
Individual circumstances
22 Is the request urgent?
For IFR purposes an urgent request
is one where a failure to provide the
specifically requested treatment
within 72 hours will have very
serious negative consequences for
the patient. In these requests, the
provider may treat first and ask for
funding retrospectively (the panel
will assess the request without
knowing that treatment has
commenced) or when a provider
believes the IFR request requires a
quick decision (i.e. before the next
meeting of the CCG IFR panel) and
where the GMCSU EUR triage team
believes the Trust has appropriately
managed the request and it
genuinely cannot wait until the next
CCG IFR Panel meeting.
Select Yes or No
IF YES, please provide a date by which a decision is required AND reasons as to
why it is urgent in the box below.
State consequences of delay in treatment if not treated within 72 hours.
Click here to enter information if YES
NOTE: if the request requires a
quick decision because, in the view
of the GMSS EUR triage team the
Trust has not appropriately
managed the request (i.e. given the
patient a date for surgery before
asking whether or not funding is
available) the Trust will need to act
in good faith and carry the financial
risk of the request being declined
and the request will be handled in
the usual way.
Document1
7 of 8
23
Statement of clinical need /
exceptional circumstances
Click here to enter text.
Please attach any relevant evidence
to support case for need /
exceptionality.
Exceptionality means ‘a person to
which the general rule is not
applicable’. A patient may be able
to demonstrate exceptionality by
showing that s/he is: “Significantly
different to the general population of
patients with the condition in
question and as a result of that
difference, they are likely to gain
significantly more benefit from the
intervention than might be expected
from the average patient with the
condition.” i.e. How will this patient
benefit more from this treatment
than all other patients with the same
condition and at the same stage?
NOTE: Social and / or psychological
factors alone will NOT be taken into
account to determine exceptionality.
However, they may be taken into
account when considering all of the
patient’s circumstances in the
round.
24
Other supporting factors
Click here to enter text.
Provide any other supporting
information felt to be relevant but
note that social factors are very
unlikely to be considered.
25
Has patient given consent
for all information relating
to their case to be shared
with the Panel?
Signature of referring clinician
Click here to enter text.
Click here to enter text.
A name is sufficient when this form is
being completed and transmitted
electronically.
By submitting this form the referrer agrees
that all the information provided is accurate
and timely.
Document1
8 of 8