Download here - Solihull CCG

Individual Funding Request (IFR) Application Form
Central Midlands
Commissioning Support Unit
NHS Birmingham Cross City Clinical Commissioning Group
NHS Birmingham South Central Clinical Commissioning Group
NHS Solihull Clinical Commissioning Group
NHS Dudley Clinical Commissioning Group
NHS Sandwell and West Birmingham Clinical Commissioning Group
NHS Walsall Clinical Commissioning Group
NHS Wolverhampton Clinical Commissioning Group
APPLICATION FORM FOR INDIVIDUAL FUNDING REQUESTS
All sections of the form must be completed otherwise the case will not be considered
Important information
Before you begin to complete this form and make an application you MUST first consider the
following question: Are there similar patients with similar clinical circumstances who could also
benefit from the treatment you are requesting across the population of the CCGs?
If the answer is YES then making an individual funding request is an inappropriate way to deal
with funding for this patient. This is because the case represents a service development for a
predictable population. You should discuss with your contract team how you submit a business
case for consideration through the usual business planning process.
Mandatory field if proceeding with the IFR
Are there likely to be similar patients who will receive the same expected benefits from this
intervention or clinical trial?
If YES, please indicate likely number of patients there are likely to be in a million population.
If the answer is NO then please proceed by completing the application, providing the information
and relevant evidence for the appropriate category of IFR into which this patient’s case falls.
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(CM CSU use only)
Case code:
Date Received:
Date assessed by IFR Team:
IFR Screening Panel Date:
IFR Panel Date:
Decision:
Decision:
Decision:
Mandatory field
1. Patient Details
Forename:
Surname:
Date Of Birth:
Patient’s Address &
Postcode:
NHS Number:
Hospital Number:
Sex: M/F:
Ethnic Origin:
(Please note that all necessary personal information will be removed from this form prior to being
reviewed. This information is collected for monitoring purposes only)
Mandatory field
2. Patient consent
Does the patient provide consent for all information regarding their case to be
shared with the Individual Funding Request Panels?
If the patient does not have the mental capacity to give informed consent, then
please confirm that you have complied with the Mental Capacity Act 2005 and the
accompanying Code of Practice.
Mandatory field
3. Registered GP Details
Registered Practice:
Registered GP Practice
Address:
Registered GP:
Telephone no:
Email Address:
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YES / NO
YES / NO
Mandatory field
4. Requesting Clinician Details
Name of Provider:
Name & Designation of
Requesting Clinician:
Address:
Telephone no:
Email Address:
Fax Number:
Mandatory field
5. Clinical Urgency
Is the patient’s
application urgent?
Processing requests takes on average one month. If the case is more urgent than this, please state why
and how urgent the case is
Mandatory field for all but requests to enter a patient in a clinical trial
6. Treatment Requested
Details of intervention
/ treatment for which
funding is requested:
Name of
treatment/intervention:
If a drug, dose and frequency:
Cost of Treatment:
Planned duration of intervention
(including number of
treatments):
Cost of the treatment:
Detail of associated costs:
(including VAT & Associated
Inpatient / Outpatient Activity):
Anticipated total cost:
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Mandatory field for all but requests to enter a patient in a clinical trial
7. Alternative Treatments
What standard
treatment does this
request replace?
Why is the standard
treatment not
appropriate?
What would be the cost
of the standard
treatment?
If this treatment request
is not approved, what
treatment will be given
to the patient?
Mandatory field for all but requests to enter a patient in a clinical trial
8. Drug status
If a drug treatment is requested, is the drug licensed for the requested indication in the United Kingdom?
If not licensed is the request:
a) Supported by the trust’s drug and therapeutics committee or equivalent?
b) Licensed in any other country?
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Copyright © 2014 Central Midlands CSU, All rights reserved.
Mandatory field for all but requests to enter a patient in a clinical trial
9. Treatment History
Details of Diagnosis &
Prognosis (for which the
treatment is requested):
Relevant medical
history:
(incl. dosage &
frequency of all
medications and comorbidities)
Previous treatments / interventions
this patient has received for this
condition:
Date/s
Intervention
(e.g. drug.
surgery)
Reason for stopping / Response
achieved
Mandatory field for all but requests to enter a patient in a clinical trial
10. Request to treat this patient as an exception
Where known, please state which commissioning policy or policies this IFR relates to:
Please set out the case for this patient being considered an exception with reference to:
 The way in which the patient is clinical different to others.
 The expected benefit expected in this patient.
 On what evidence you base the assertion that this patient will benefit more than other patients OR
Where a request is being made to use a treatment experimentally in an individual case please set
out the evidence on which benefit has been inferred.
 Any other material factors which have bearing on the case.
The case can be submitted either on this form or in a letter to be attached to this form.
Please attach any evidence in support of the benefit of treatment in this patient you consider is exceptional
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Copyright © 2014 Central Midlands CSU, All rights reserved.
Mandatory for requests to enter a patient into a clinical trial
11. Requests for treatment costs or pick-up costs to enter a
single patient into a clinical trial
The trial protocol (not the summary) must be submitted with the IFR request.
Confirm that the patient
meets the clinical entry
criteria?
Full name of the clinical
trial:
The trial registration
number (state which
register):
Funding being sought:
(please provide a
breakdown of all costs)
Mandatory – ALL
12. Declaration
To the best of my knowledge I have given the most accurate and up to date information regarding
this patient’s clinical condition.
Name
Position/Title
Signature
Provider Trust support for the application
Name
Position/Title
Signature
Date Completed
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Copyright © 2014 Central Midlands CSU, All rights reserved.
On Completion
Email through the appropriate Clinical Commissioning Group via the nhs.net account to dedicated email:
Birmingham Cross City CCG
[email protected] Harinder Kaur
0121 612 1653/612 1659
Birmingham South Central CCG
[email protected]
Terri-Ann Millington 0121 612 1645/612 1660
Solihull CCG
[email protected] Terri-Ann Millington 0121 612 1645/612 1660
Wolverhampton CCG
Walsall CCG
Sandwell CC
Dudley CCG
[email protected]
Sylvia Woodhall
[email protected] Sylvia Woodhall
[email protected]
Sylvia Woodhall
[email protected] Denise Bell
0121 612 1408/612 3512
0121 612 1408/612 3512
0121 612 1408/612 3512
0121 612 1636/612 1661
For generic queries email: [email protected] or Fax to safe haven: 0121 285 5990
or Post (Marked Confidential) to:
IFR Team
Central Midlands CSU
Kingston House
438-450 High Street
West Bromwich
West Midlands B70 9LD
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Copyright © 2014 Central Midlands CSU, All rights reserved.