Penile Conditions - Surgical Opinion and Treatment

INCLUDING Circumcision in all male patients OVER the age of 18 years

Application for Prior Approval of Funding

STRICTLY PRIVATE AND CONFIDENTIAL

PART A: THIS PAGE MUST BE COMPLETED FOR ALL REQUESTS

PATIENT INFORMATION
Name / Male / Female
Address
Post Code
Date of Birth / NHS Number
Referrer’s Details (GP/Consultant/Clinician):
Name
Address
Post Code
Telephone / Email
GP Details (if not referrer):
Name / Practice
By submitting this form you confirm that the information provided is, to the best of your knowledge, true and complete and you confirm (please clarify in the box below) that you have:
·  Discussed all alternatives to this intervention with the patient.
·  Had a conversation with the patient about the most significant benefits and risks of this intervention.
·  Advised the patient that NHS Decision Making Aids are available online should the patient wish to access them at http://sdm.rightcare.nhs.uk/pda/
·  Informed the patient that this intervention is only funded where criteria are met or exceptionality demonstrated.
·  Checked that the patient is happy to receive postal correspondence concerning their application.
·  Discussed with the patient whether any additional communication requirements (e.g. different language, format or limited capacity) are needed (please specify requirements in the box below).
ANY REQUESTS NOT COUNTERSIGNED BY A SENIOR CLINICIAN/Salaried
or Partner GP WILL BE RETURNED.
Clarification/Communication Needs:
I understand that it is a legal requirement for fully informed consent to be obtained from the patient (or a legitimate representative of the patient) prior to disclosure of their personal details for the purpose of a panel/IFR team to decide whether this application will be accepted and treatment funded. By submitting this form I confirm that the patient/representative has been informed of the details that will be shared for the aforementioned purpose and consent has been given.
SIGNED REFERRER: ………………………………….….………………… DATE: …………………...
CATEGORY / VERSION / CATEGORY / VERSION / CATEGORY / VERSION
Bristol / Prior Approval / 1718.1 / North Somerset / Prior Approval / 1718.1 / South Gloucestershire / Prior Approval / 1718.1

PART B: THIS PAGE MUST BE COMPLETED FOR ALL REQUESTS

If your patient does not meet the following criteria then please ALSO fill out Part C of this form outlining

the patient’s exceptionality. If the criteria are met you only need to complete Parts A and B.

Funding approval for surgical treatment will only be provided by the CCG for patients meeting one of the criteria set out below:
Adult Patients over 18 years
1.  Pathological Phimosis (inability to retract foreskin)
Has the patient suffered with symptoms of Balanitis Xerotica Obliterans (BXO) including one or more of the following:
a)  An inability to retract the foreskin
b)  White scarring
c)  Fissures
d)  Redness of the prepuce
e)  Weeping
Please provide the relevant documented evidence of symptoms with this application
OR
2.  Physiological Phimosis (foreskin can be retracted but is tight)
A referral for Consideration of Surgical Treatment will be funded where a patient meets the following criteria:
a)  Has the patient been suffering from recurrent obstruction, haematuria or pain, specifically 3 documented episodes in the preceding 12 months?
AND
b)  Has treatment with topical steroids (0.05%-0.1% betamethasone or equivalent) been tried for 8 weeks and proved ineffective as documented within the patient’s clinical records?
NB: Non retractile ballooning of the foreskin and spraying of urine do not need to be referred for circumcision routinely
OR
3.  Paraphimosis which has required medical attention to reduce:
a)  Does the patient have more than one documented episode of clinically significant Paraphimosis in the preceding 12 months?
Please provide the relevant documented evidence of symptoms with this application / YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
OR
4.  Balanitis / Balanoposthitis
A Referral for Consideration of Surgical Treatment will be funded where a patient meets the following criteria:
a)  Has the patient suffered from recurrent Balanitis/ Balanoposthitis, specifically 3 episodes in the preceding 12 months, and are these documented in the patient’s Primary Care Record?
AND
b)  Has a minimum of 8 weeks’ conservative methods (e.g. hygiene, topical steroids) been tried and proved ineffective and is this documented within the patient’s clinical records? / YES NO
YES NO
NOTE:
If you have any concerns that symptoms relate to malignancy,
you should refer via the 2 Week Wait pathway
Please note for female patients: Female Circumcision often known as Female Genital Mutilation (FGM) is prohibited by law (Serious Crime Act 2015) and will therefore not be funded by the Commissioner. Incidences where parents seek advice on FGM must be reported to the local Children Safeguarding Team.
Please provide evidence below to support the information you have provided.
Without evidence this application will be rejected.
The patient is also welcome to provide a statement, to include examples of
Significant Functional Impairment.
Supporting Information

PLEASE SEND THIS FORM TO THE CCG IF THE ABOVE CRITERIA ARE FULLY MET AND EVIDENCED. IF NOT, PLEASE GO ON TO COMPLETE PART C

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Part C: INDIVIDUAL FUNDING REQUEST

Only Complete if Patient DOES NOT MEET THE CRITERIA IN PART B

Exceptionality / Please note that not meeting the criteria is not in itself exceptional. The sections below must be completed, clearly outlining a comprehensive and thorough case for the exceptionality of your patient, to enable the IFR Panel to reach a funding decision.
Explain why the patient is significantly different to the general population of patients with the condition in question
Explain why the patient is likely to benefit more from the intervention than might normally be expected for patients with that condition:
Brief and relevant health history, including patient’s current health status and any other co-morbidities, health issues and current medication.
Clinical History
relevant to the case
What treatments has the patient tried? Is this patient unable to tolerate the usual care? What services has the patient been referred to?
The completed form should be sent in confidence with any other supporting documents to:
North Somerset CCG
By email to:
By post to:
Referral Support Service
Post Point 11
Clevedon, North Somerset
BS21 6FW / Bristol CCG / South Gloucestershire CCG
By email to:
By post to:
Individual Funding Request Team
Suite 15, Corum 2
Corum Business Park,
Warmley, South Gloucestershire, BS30 8FJ
In order to comply with information governance standards, emails containing identifiable patient data should only be sent securely, i.e. from an nhs.net account.

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