Central Southern
Commissioning Support Unit

INDIVIDUAL FUNDING REQUESTS PANEL (IFR)

EXCEPTIONAL CIRCUMSTANCES SUBMISSION FORM

On completion, please return to:

Individual Funding Request (IFR) Team, Central Southern Commissioning Support Unit email:

Please ensure that the information is sent in a secure manner.

PLEASE NOTE IF THIS APPLICATION IS NOT COMPLETED IN FULL AND ASSOCIATED PAPERS ARE PROVIDED TO SUPPORT THE FUNDING REQUEST, THIS WILL DELAY A RESPONSE FROM THE INDIVIDUAL CASE REVIEW PANEL.

CONTACT INFORMATION
HOSPITAL/GP NAME requesting funding
  1. Hospital/GP PracticeAddress

  1. Applicant Details
/ Name of Consultant/GP:
Designation:
Tel:
Email:
  1. Patient Details
/ Initials:
NHS number:
Hospital ID number:
DoB:
Named Consultant:
Registered GP name:
Registered GP postcode:
Referred by (other than GP):
Referred from:
Date of referral:
  1. Application reviewed by Chief Pharmacist or nominated deputy e.g. relevant directorate pharmacist (in the case of a drug intervention)
/ Name:
Signature or email confirmation:
INTERVENTION REQUESTED (NB: Intervention refers to requested treatment, investigation, etc)
  1. Patient Diagnosis (for which intervention is requested)

  1. Details of intervention (for which funding is requested)
(If required, seek advice from pharmacy) / Name of intervention:
Dose and frequency:
Route of administration:
Anticipated monthly cost, or cost per cycle (inc VAT)
Inclusive Cost
  1. (a) Planned duration of intervention?
    Doses?
    Frequency?
    How many cycles will be needed to assess efficacy of treatment?

(b) How will you monitor the
effectiveness of the intervention?
(c) What would you anticipate to be a successful outcome for this intervention in this patient?
d) Has the patient been fully informed regarding this treatment, it’s outcomes etc?
Has the patient agreed to this treatment going ahead if funding is approved?
  1. Is requested intervention part of a clinical trial?

If Yes, give details (e.g. name of trial, is it an MRC/National trial?)
What is the exit strategy?
  1. (a) Is there a standard intervention at this stage?

IfYes include details / standard algorithm of care for disease type.
(b) Is the requested
intervention additional to the
standard intervention(s) or a
deviation from the standard
(c) Is this fully compliant with NICE guidelines?
If No, please state the exceptionality for this case?
(d) Is this treatment less than £30K per QALY?
(e) What are the exceptional circumstances that make the standard intervention inappropriate for this patient?
  1. (a)In case of intervention for cancer:
/ Please indicate whether the intervention is for
-Adjuvant / Neoadjuvant
-1st line relapse (or metastatic)
-2nd line relapse
-other (please specify)
What was their previous response to treatment?
What was their time to relapse and how did this compare to other patients treated with the same regimen?
What is the WHO performance status?
How advanced is the cancer? (stage)
Describe any metastases:
What other alternative treatments/radiotherapy/surgery are available at this stage of the disease?
What markers/ tests will be used to monitor the impact of the treatment?
Would the patient be willing to consent to the proposed treatment?
10. (b) In case of intervention for
non-cancer: / What is the patient’s clinical severity? (Where possible use standard scoring systems e.g. WHO, DAS scores, walk test, cardiac index etc.)
  1. Summary of previous intervention(s) this patient has received for the condition.
* Reasons for stopping may include:
  • Course completed
  • No or poor response
  • Disease progression
  • Adverse effects/poorly tolerated
/ Dates / Intervention (e.g. drug / surgery) / Reason for stopping* / Response achieved
  1. Anticipated start date
/ Processing requests can take up to 2 weeks(from the date received by the PCT). If the case needs to be fast-tracked, please state why:
As soon as possible.
CLINICAL EVIDENCE
  1. Is requested intervention licensed in the UK for use in the requested indication
/ If No is it licensed for use in another indication?
  1. Has the Trusts Drugs and Therapeutics Committee or equivalent Committee approved the requested intervention for use?(if drug or medical device).
/ If No, is it Committee Chair or Chief Pharmacist approved:
Please supply evidence e.g. letter from D&TC access to minutes of meeting
  1. In case of intervention for cancer has it been approved by the:

(a) Drug Evaluation Committee
(b) Cancer Network Site specific
tumour board
  1. Give details of National, Cancer Network or Local Guidelines/ recommendations or other published data supporting the use of the requested intervention for this condition?
/ PUBLISHED[1] trials/data (please forward papers / web links for peer-reviewed papers where available)
See attached
If the treatment result in public trial is relatively modest is there a sub-group who responds better?
Is the sub-group that respondssignificantly better to the intervention identifiable?
Do you expect this patient will be part of the sub-group with the better prognosis?
  1. What is the anticipated benefit of the intervention compared to the standard?
/ In case of intervention for cancer please provide details of expected survival benefit.
What are the risks to the patient from the proposed treatment?
Is there any QOL information? If no formal review, what impact do you think it will make from social point of view e.g. keep working, support their family, be able to self-care, etc?
  1. What is the anticipated toxicity of the intervention for this patient?

  1. Are there any patient factors (clinical or personal) that need to be considered?
/ Please feel free to attach a letter to accompany your request for funding.
Date form completed:
Trust reference number:
Consultant request:
Name: Signature:
Date:

ConfidentialPage 1 of 5

April 2013

[1]Full published papers, rather than abstracts, should be submitted, unless the application relates to the use of an intervention in a rare disease where published data is not available