Application form

Individual Funding Request Panel

Application for treatments not normally funded by NHS Gloucestershire Clinical Commissioning Groupi.e.treatments for patients with exceptional clinical circumstances to current treatment policy or individual request for experimental treatment.

Notes for completion

Further information about the application process is provided in the IFR policy and appendices available on the Gloucestershire Clinical Commissioning Group website:

1) In making a case for individual funding request it needs to demonstrate that

  • the patient is significantly different to the general population of patients with

the condition in question and

  • the patient is likely to gain significantly more benefit from the intervention

than might be normally expected for patients with that condition.

2) All areas must be completedelectronicallyand sent in confidence with any other supporting documents, to:

3)It is the responsibility of the Clinician to detail sufficient clinical evidence in the application and to providecopies of research or other documentary evidenceto support the application. Applications without supporting informationwill be returned to the Clinician and will not be considered by the Panel.

4)For secondary and tertiary care applications:

All treatment requests must be approved by the Chief of Service or Specialty Director.

I confirm that I have fully discussed this application with my patient and the patient hereby gives consent for disclosure of information relevant to their case from professionals involved and to the CCG.

Managing clinician

PRINT NAME: GMC registration no:

Address:

Date:

Secondary and tertiary care applications only.
Agreed and authorised by the Chief of Service or Specialty Director
PRINT NAME SIGNATURE or email confirmation of authorisation

1.Patient’s details

NHS Number: / MRN Number:…………………
GP: name & surgery

2. Brief history including patient’s current health status and any other relevant health

care problems

3. Summary of previous interventions this patient has received for this condition

4. Details of the treatment/equipment for which funding is requested

For drug requests, please state if it is licensed for this indication YES / NO
Discussed in MDT: YES / NO
Outcome of meeting:
Has this been agreed with the Trust Prescribing Lead: YES / NO

5. What are the intervention goals and expected outcomes following treatment?

6. Is any alternative treatment/equipment available? Is this alternative commissioned

by NHS? Why is this alternative not appropriate for the patient?

7. Proposed provider of the treatment (include any alternative providers, if appropriate)

8. Cost (if information available) and length of treatment, if known

Cost: £ / Length of Treatment:
Preferred start date (and reason)

9. Evidence that the treatment proposed has the potential to result in health

improvement for the patient, including recent evidence of effectiveness/NICE guidance etc. (A policy not to commission a service/therapy usually reflects a lack of evidence of effectiveness, or evidence of limited benefit balanced against adverse effects.

please provide details of research/clinical evidence that supports this particular application).

10. Implications for the patient if proposed treatment is not funded

11. Proof of ‘Exceptionality’ - rationale for bringing this case to the Individual Funding

Request PanelFor applications to fund cosmetic problems, accompanying photographic

evidence is also requested.(NB It is the applying clinician’s responsibility to obtain

consent from the patient for photographic evidence to be used for this purpose.)

12. Are there likely to be other similar patients?

13. Patient’s submission in support of their case:

Has this patient been made aware this application is being made? Yes No

Has the patient been asked to submit accompanying information in support of their case?

Yes:No:

If so is the submission:attached to this application or being provided separately

Communication of the decision

It is Gloucestershire Clinical Commissioning Group’s policy to communicate the decision of the Panel to the referring clinician, with a copy to the patient’s GP (unless otherwise advised), therefore please discussthe outcome of this application with your patient.

The completed form should be sent with any other supporting documents electronically to:

August 2016

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