Download Funding Request Form - North West Commissioning Support Unit

GM EUR FUNDING REQUEST FORM
Sacroneuromodulation for Urinary Retention and Constipation
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
Central Manchester CCG
Heywood, Middleton & Rochdale CCG
North Manchester CCG
Oldham CCG
Salford CCG
South Manchester 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
Sacroneuromodulation for Urinary Retention and Constipation
Sacroneuromodulation is considered a developmental treatment in relation to urinary retention and
constipation and will only be commissioned:
 for Fowler’s Syndrome (the diagnosis should be confirmed by EMG)
 as part of a commissioned trial
Funding will be available on an individual patient basis, for those patients, who meet NICE IPG 536; with
a diagnosis of Fowler’s Syndrome, or where evidence of exceptionality is demonstrated. Individual Prior
Approval should be sought in line with the procedures described in the Greater Manchester Effective
Use of Resources Operational Policy.
NOTE: Sacroneuromodulation for faecal and urinary incontinence are currently commissioned by NHS
England.
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
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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
Click here to enter text.
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14 NHS No.
Supporting Information
15 Does the patient have
Fowlers Syndrome
(confirmed by EMG)?
Click here to enter text.
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Click here to enter text.
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Select Yes or No
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Medical History
16 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
17 Who will provide this
treatment / intervention?
Click here to enter text.
Referrer or other provider?
18
What is the cost of the
treatment?
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Known / estimated total cost if time
limited / one off OR known /
estimated annual cost if on-going.
19
Has the patient been
informed of any additional
clinical risks involved with
the proposed treatment?
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Please outline risks.
Individual Circumstances
20 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.
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21
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.
22
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.
23
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.
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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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