Download Individual Funding Request (IFR)

GM EUR FUNDING REQUEST FORM
GENERIC
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
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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.
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GM EUR Funding Request Form
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.
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(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
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7
Telephone number
8
Email address
Patient details
9
Name
10 Postcode
11 Date of birth
12 GP name
13 GP address
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14 NHS number
Supporting information
15 Is the patient willing to
submit non-identifiable
photographs OR are
medical illustrations
available?
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Non-identifiable photographs,
preferably medical illustrations if
available, will be requested, to
support the decision making
process, but will not form the sole
basis of the decision. It is not
mandatory for photographs to be
provided by a patient.
Only if relevant to the request.
16
Patient’s BMI
Click here to enter text.
Only required for requests for
aesthetic surgery e.g. apronectomy,
breast reduction, etc.
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Medical history
17 Patient’s clinical diagnosis
and summary of clinical
condition
Click here to enter text.
Condition requiring treatment with
requested drug / procedure device
or referral. Please supply as much
detail as possible about: severity,
duration and prognosis. Include
disease markers / disease activity
scores / objective methods of
measuring disease severity if at all
possible.
18
State the previous
treatment(s) which have
been tried to treat this
condition AND the
outcomes achieved AND
also state any treatments
currently being given
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Please detail all interventions tried,
start and end dates, and reasons for
stopping / or response achieved.
This will usually include standard
treatment(s).
19
Any other relevant past
medical history
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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.
Details of treatment requested
20 Details of drug / procedure
/ device or nature of
referral requested
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Please provide full description of
intervention if not already stated.
21
Anticipated duration of
treatment
Click here to enter text.
(One-off; days / months / lifetime /
assessment / number of sessions
etc.)
22
Who will provide this
treatment / intervention?
Click here to enter text.
Referrer or other provider?
23
Evidence of effectiveness –
patient selection criteria;
(hierarchy of evidence level
etc.)
Click here to enter text.
Attach papers / web link to NICE /
SMC / local / national guidance /
guidance from professional bodies
etc. If application is in accordance
with NICE guidance, make clear
how the patient meets NICE criteria.
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24
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.
25
Expected (objective)
outcomes of the treatment
for this patient
Click here to enter text.
What benefit would you expect the
patient to derive from this new
treatment / intervention? This
should be expressed as a patient
orientated outcome e.g.
improvement in pain score,
increased functionality, rather than a
disease orientated outcome e.g.
physiological marker.
26
Exit criteria / review date
Click here to enter a date.
Please provide details including
time frame for assessing whether
intervention is worthwhile.
27
Is the drug / intervention
requested licensed for the
identified indication?
Click here to enter text.
Please give details
28
Is the drug being used as
part of a clinical trial?
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If so, please provide information on
how ethical approval was obtained
and details of post-trial funding
arrangements.
29
Has the patient been
informed of any additional
clinical risks involved with
the proposed treatment?
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Please outline risks
30
For an intervention to be
carried out in NHS
secondary or tertiary care:
1. What is the Trust view?
2. Has the drug been
considered by the D&TC
or other processes?
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Please provide date / details of
approval by an appropriate D&TC
(Drug & Therapeutic Committee).
Note: approval does not mean the
request will be approved.
Individual circumstances
31 What are the implications
of not providing this
treatment?
Click here to enter text.
Short-, medium- and long-term
health implications for this patient.
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32
Is the request urgent?
Select Yes or No
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.
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.
33
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.
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34
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.
35
Has patient given consent
for all information relating
to their case to be shared
with the Panel?
Signature of referring clinician
Select Yes or No
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.
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