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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 Document1 1 of 5 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 5 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. 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 Does the patient have Fowlers Syndrome (confirmed by EMG)? Click here to enter text. Document1 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 3 of 5 Medical History 16 Any other relevant past medical history 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. 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? Click here to enter text. 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? Click here to enter text. 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. Document1 4 of 5 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. 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 5 of 5