Download IFR application form with IG statement

Individual Funding Request (IFR) Application Form
All applicants must ensure that this form has been read in conjunction with the local Clinical
Commissioning Group (CCG) Individual Funding Request (IFR) Policy. The IFR Panel will accept
applications from clinicians on the understanding that clinicians have read and are familiar with the
aforementioned policies.
The purpose of the IFR process is to provide a mechanism for considering the needs of individual
patients whose personal circumstances might make them an exception to CCG commissioning
policies.
Please note that the IFR process cannot be used to make commissioning policy decisions, hence
the IFR Panel cannot make decisions to fund a treatment whereby so doing would set a precedent
that establishes new policy (because the patient is not exceptional but representative of a definable
group of patients).
Please note that it is the responsibility of the applying clinician to complete this form in full and
provide relevant evidence. If essential information is left off the form or responses need additional
information, the application will be returned to the applicant for completion, thus delaying the
application.
NOTE: If you are applying for a Procedure of Limited Clinical Value/Effectiveness (POLCV/E)
please refer to the policy and separate application form on your CCG website
Information Governance Statement
All Individual Funding Requests (IFR) may be reviewed by the Clinical Commissioning Group
(CCG) as the statutory body responsible for funding decisions. This application form and any other
supporting information supplied may therefore be shared with the CCG or other trusted
organisations legitimately acting on behalf of the CCG. Personal information may be retained only
for the purposes of this IFR and, in some cases, may be used for invoicing and payment
reconciliation. Anonymised information may also be shared as part of CCG reporting processes.
PLEASE SIGN OR TICK BELOW TO INDICATE THAT YOU:
1. Have discussed the Information Governance Statement with your patient and that they give
their consent for information about their case to be used to process their application in
accordance with the provisions of that statement.
2. Will take full responsibility for informing the patient about the IFR process including
informing them of the funding decision and their right of Appeal (if necessary).
Please tick 
Applicant’s signature
Signed by: ……………………………………………..…….. Date signed: ….……/…..……/..…….
Print name: …………………………………………………..
All forms must be signed by the NHS Practitioner (unsigned forms will not be accepted)
Secondary Care Individual Funding Request Application Form 2013/14 (January)
1. Treatment
requested:
2. Indication:
3. Is this application
urgent?
Please provide
detailed reasons for
urgency.
NOTE: If this is an urgent application please telephone the IFR team
once you have sent your application on 0203 688 1290.
Contact Information:
4. Date of application
5. Applicant details
Name
Designation
Tel
Email – please
provide secure
nhs.net address for
all related
correspondence
NOTE: only nhs.net addresses are acceptable
for confidentiality reasons
GP Practice
GP Practice
postcode
GP practice code
CCG
6. Patient details
Patient initials:
Patient NHS
Number:
DoB:
Male / Female
NOTE: Please read carefully the next sections on how to proceed with your funding application as
incomplete information will delay the decision process.
Please do not include any patient identifiable data from this point forward in the application (Name,
initials, DoB, age, gender etc.)
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
PROVIDER TRUST APPROVAL
7. Which
organisation will
be providing the
treatment
requested
NHS Trust:
GP practice:
dental practice:
other:
Non-NHS:
Name of provider
Address of provider
8. Approved by a
representative of
the NHS Provider
that will provide
the treatment
9. If this funding
request is
approved please
give details of the
person who
should be
notified
Name of
representative:
 chief pharmacist
or chair of DTC if
a drug request
 clinical director
for diagnostic or
surgical
procedure
Designation
Signature or e-mail
confirmation
Name:
Designation:
Contact details
NEL CSU USE ONLY
Date received
IFR Identifier
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
SECTION 1
DIAGNOSIS AND PATIENT’S CURRENT CONDITION
10. Diagnosis (for which
the intervention is
requested), plus date of
diagnosis and summary
of any other relevant
medical history
11. Please describe the
impact of the condition on
the patient in terms of
symptoms, quality of life
etc.
12. Please describe the
patient’s clinical severity
using where possible
standard scoring systems
e.g. WHO, DAS scores,
walk test, cardiac index
etc.
13. What are the likely
consequences for this
patient if funding is not
approved?
14. Summary of previous treatment the patient has received for this condition
Start
date
End
date
Intervention (e.g.
drug / surgery)
15. What is the standard
intervention for this type of
patient?
Reason for stopping/response achieved
Please include details / standard algorithm of care for disease
type.
16. Why is the standard
intervention inappropriate for
this patient?
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
SECTION 2
DESCRIPTION OF THE INTERVENTION FOR WHICH FUNDING IS REQUESTED
17. Name of the intervention
18. Is the intervention a
continuation of an existing
treatment funded via another
route?
If Yes, give details of the existing funding arrangement
and why this has ceased.
19. Is the intervention part of a
trial or research?
If Yes, give details (e.g. name of trial, is it an MRC/National
trial?)
20. Where will the intervention
be provided?
SECTION 2a
FUNDING REQUESTS FOR DRUGS
21. Full name of the drug and
the manufacturer
22. Planned dose and
frequency
23. Planned duration of
intervention
24. Route of administration
25. Planned start date
26. If the intervention forms
part of a drug regimen,
please document the
regimen in full
27. Has the drug been
approved by the Trust’s
internal pharmaceutical
committee
28. Is the drug listed as a
PbR exclusion?
29. Estimated costs
Delete as appropriate: Yes / No
Anticipated cost including VAT
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
Please consult your Pharmacy
team for current contract prices
per cycle and total as these
may differ from those given in
the BNF or other sources
Describe type and value of any offset
costs
Funding difference being applied for
SECTION 2b
FUNDING REQUESTS FOR DIAGNOSTICS, DEVICES OR SURGICAL PROCEDURES OR
OTHER THERAPIES
30. Name of the intervention
31. Specify the device,
prosthesis etc where
relevant and the
manufacturer
32. Estimated costs
Anticipated cost including VAT
Please consult the relevant
business manager for
assistance
Describe type and value of any offset
costs
Funding difference being applied for
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
SECTION 3
MONITORING PARAMETERS AND PROJECTED OUTCOMES
33. How will you monitor the
effectiveness of the
intervention?
34. What is the minimum
timeframe after which a
clinical response can be
assessed
35. What would you consider
an achievable successful
outcome for this intervention
in this patient?
SECTION 4
EVIDENCE of CLINICAL EFFECTIVENESS
36. What is the evidence that
this intervention is likely to
be effective in this type of
patient
Please cite full peer reviewed,
published papers rather than
abstracts and attach (for
journals that require
subscription) or web-link for
open access publications of
relevant trials/data.
37. Give details of National,
Regional or Local Guidelines/
Recommendations or other
published data supporting the
use of the requested
intervention for this condition.
38. What is the anticipated
benefit (from current
published evidence) of the
intervention compared to the
standard?
39. What are the potential
adverse events of the
intervention for this patient?
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
SECTION 5
CLINICAL EXCEPTIONALITY
40. Please provide
prevalence/incidence rates
for this particular
stage/presentation of the
condition, and
prevalence/incidence rate
How many patients with the
same condition or
presentation as this patient
would you expect to see over
12 months?
41. Please describe how the
clinical presentation of this
patient differs from other
patients with this condition
42. Please describe how this
patient might be expected to
gain greater health benefit
from this intervention
compared to other patients
with this condition
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
ARE THERE ANY OTHER RELEVANT PATIENT FACTORS THAT THE IFR PANEL SHOULD
CONSIDER?
Note: the IFR Panel decision making process will focus on why the patient is more likely to
benefit clinically than the rest of the group for whom funding is not available. This means
that personal characteristics, such as age, family status, employment etc. which could
discriminate against other local residents will only be considered if they are relevant
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
Individual Funding Request (IFR) Application Forms
should be returned
by Post:
IFR
NHS North and East
Commissioning Support Unit
2nd Floor
Clifton House
75-77 Worship Street
London
EC2A 2DU
by Confidential Email:
Barking and Dagenham
[email protected]
Havering
London
Redbridge
Contact the IFR team by telephone on:
020 3688 1290
[email protected]
[email protected]
Waltham Forest
Newham
Tower Hamlets
City and Hackney
Barnet
Camden
Enfield
Haringey
Islington
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Secondary Care Individual Funding Request Application Form 2013/14 (January)
GUIDANCE NOTES FOR CLINICIANS COMPLETING THIS IFR FORM
IFR Policy and further information
The IFR Policy and other policy documents are available from the IFR team, please contact the team on
the relevant email on page 9.
Before submitting an IFR, please check that this is the correct process. IFRs can be submitted by an NHS
consultant, a GP or dental practitioner, or an equivalent autonomous practitioner where he/she will be
responsible for administering the treatment. The requesting clinician is responsible for providing all
supporting information and evidence.
Information Governance and patient consent
Providing either a signature or tick box validates this request and indicates that you have discussed
the request with the patient, and that the patient has given consent to the submission. If this section is
left incomplete the form cannot be accepted, and we will inform you of this accordingly.
Details of patient and clinician submitting the request
It is essential that you please provide full contact details including an nhs.net email address, to enable us
to easily communicate with you while this case is being processed, and to inform you of the final
outcome.
We must be able to identify the patient; provision of the patient’s NHS number is also essential. Please
note that patient details will not be available to the Panel to ensure anonymity. Please help the IFR Team
by not referring to the patient name or initials within the form – the only section which should contain
patient demographic details is page 2, which will be anonymised for Panel.
Diagnosis and the patient’s current condition/ Intervention for which funding is requested
The fullest possible information will help the Panel make a decision. Please ensure all relevant sections
are completed depending on the type of intervention.
Interventions
Information on likely costs helps the CCG to be aware of potential cost pressures; the fullest possible
information will help the Panel come to their decision.
Please give details of the standard intervention the patient would otherwise receive if this application was
not being submitted. This is necessary to compare the evidence of efficacy for the standard intervention
against the proposed intervention.
Interventions involving drugs
Comprehensive information and accurate references will avoid any delay in this IFR being processed.
Statement of clinical exceptionality
Clear evidence of patient exceptionality is essential in order to enable the IFR Panel to reach a funding
decision. Please state as clearly as possible, with reference to the existing policy if relevant, why this
patient should be treated as an exception. Evidence must be submitted to demonstrate how this patient’s
clinical condition is significantly different to other patients with a similar condition, and in addition how
this patient is likely to gain a greater health benefit compared to others in the cohort of similar patients.
The IFR Team aims to deal with all applications in a timely manner. A funding outcome can only be
reached where sufficient information is available to inform the decision. Urgency will be evaluated on the
basis of clinical need.
Please contact the IFR Team on 020 688 1290 for further information or clarification.
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