Procedure that requires prior approvalApplication form: - Surgery for Stress Incontinence
Name of Referring ClinicianGP Name and Surgery
Patient NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? / Yes ☐No ☐
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? / Yes ☐No ☐
Is this a patient/guardian led application? / Yes ☐No ☐
Most Urgent: Decision needed within a week as the patient’s life may be in danger. / ☐ /
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. / ☐ /
Routine: Decision needed in 4 to 6 weeks. / ☐ /
This form is to be completed by the GP/Consultant when applying for funding for individual patients for clinical procedures which require Prior Approval or Procedures Not Routinely Funded.
Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration.
The policy statements are available at:
Please note that unless there are exceptional health needs clearly demonstrated in the form which are deemed acceptable by the panel, it is unlikely that funding will be approved.
Please complete the following sections in full. Incomplete applications will not be considered and will be returned.
Clinical Criteria required for consideration of treatment / Please Tick- Has the patient undergone a trial of supervised pelvic floor muscle training with a physiotherapist with an interest in pelvic floor dysfunction for a minimum of 3 months?
- Have the community continence team assessed the patient and found the patient not suitable for supervised pelvic floor exercises?
- Does the patient have stress incontinence combined with pelvic prolapse etc?
- Which of the following procedures does the patient require?
a) Retropubic mid‐urethral tape procedures using a ‘bottom up’ approach with macroporous (type 1) polypropylene meshes
c) Autologous rectus fascial sling
If unsuitable which procedure do you wish to undertake?
Please provide details
- Please provide the patient’s:
Height / cm
Weight / kg
- Is the patient a non-smoker?
- Why do you think this patient should be an exception to current policy or considered to have an exceptional health need for the intervention requested? (please see footnote for definition)
SIGNATURE OF CLINICIAN …………………………………………………………….DATE: …………………………………………………..
Please email the completed form to for consideration.
*Exceptional Status (what makes the individual sufficiently different from the ‘usual’ in policy terms) Central to consideration of individual requests for funding is the concept of the case being exceptional.
In order for funding to be agreed there must be unusual or unique clinical factors about the patient that suggest that they are:
•Significantly different to the general population of patients with the condition in question
and
•likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition.
However:
•The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception.
•If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional.
•Social value judgements (the 'worth’ of patients) are not relevant to the consideration of exceptional status but there may rarely be exceptional circumstances where benefits may go beyond the patient (e.g. as a carer) in respect of social or health related benefits for others.
Management of Psychological Issues: The NICE clinical guideline on BDD(obsessive compulsive disorder; clinical guideline 31; National Institute for Health and Clinical Excellence) states that for people known to be at higher risk of BDD or people with mild disfigurements or blemishes who are seeking a cosmetic procedure, ALL healthcare professionals should routinely consider and explore the possibility of BDD.
Therefore clinicians seeing a patient who requests cosmetic surgery should perform a BDD triage as per NICE guidance (Clinical Guideline 31: Obsessive compulsive disorder and body dysmorphic disorder. Full guideline section 10.4.2.2; page 230) and those with suspected or diagnosed BDD seeking cosmetic surgery or dermatological treatment should be assessed by a mental health professional with specific expertise in the management of BDD (section 10.4.2.3).
Patients’ whose desire for surgery reflects serious psychopathological disorders (such as Body Dysmorphic Disorder (BDD), or irredeemable relationship problems would not normally be suitable for surgery but should receive appropriate alternative treatment and support.
South, Central and West Commissioning Support Unit October 2015 BD