· This form should be used by Practitioners who would like to request that a dressing is added to the Wound Care Formulary for implementation in NHS organisations within the following areas: Calderdale, Kirklees, Wakefield and Pontefract District.
· Requests may be submitted by Tissue viability nurses (TVNs), specialist nurses, Consultants/GPs, Practice/District nurses and Podiatrists
· Requests will be considered by the Wound Formulary Group, a sub-committee of South West Yorkshire Area Prescribing Committee, which meets bi-monthly. The Wound Formulary Group performs a peer review assessment, reviewing safety, efficacy & cost effectiveness.
· This form should be completed electronically & e-mailed to following discussion with your local Tissue Viability Nurse
Product requested – delete options that do not apply
Dressing name
/Preparation
/Size
Indication for which you would like to use the dressingProposed patient selection criteria
Does the product have a UK Product Licence or CE mark / Yes / No
Do you intend to use the product in accordance with the Product Licence? / Yes / No / N/A
Please indicate where you would like to use the new product. / § Calderdale Primary care
§ CHFT
§ Kirklees Primary care
§ MYHT
§ Wakefield and Pontefract District Primary care
§ SWYMHT
Specialist support – delete options that do not apply
Has this request been endorsed by a Tissue Viability Nurse Specialist? / § If yes, please give their name______
§ If no, why not?
Rationale for request – delete options that do not apply
Reason for request / § Alternative to existing product(s)§ Different size
§ Different preparation eg. tulle, gel
If product requested as an alternative, please specify current dressing options
State the clinical rationale for requesting this product. For example:
§ Increased effectiveness
§ Reduced adverse effects
§ Ease of application / removal
§ Patient satisfaction / compliance
§ Reduced pain
§ Cost
Please submit this section on a separate sheet if that is easier.
Clinical papers (eg RCTs, case studies) must be included, either attached electronically or forwarded in hard copy / § Electronic copy e-mailed with request
§ Sent by post
Anticipated usage
How many patients would you expect to treat with this product over the next 12 months? / § Less than 10§ Between 10 - 50
§ More than 50
§ Other (please specify)
Prescribing responsibility – delete options that do not apply
Who do you think should be responsible for initiating this product? / § Any prescriber§ TVN recommendation only
§ Initiation by hospital specialist who will prescribe the initial supply before referral to primary care
If specialist initiated, who should be responsible for following-up patients prescribed this product? / § Hospital TVN
§ Hospital specialist
§ Community TVN
§ District nurse
§ General practitioner
§ Podiatrist
§ Shared responsibility
When will treatment be reviewed and decision made to stop/continue treatment?
What is the expected duration of treatment?
Anticipated expenditure
What is the cost of this dressing per patient?Basic NHS cost of primary dressing
Basic NHS cost of any secondary dressing
Frequency of dressing change
Expected duration of treatment
Estimated total cost
What is the cost of the current Formulary alternative dressing per patient?
Basic NHS cost of primary dressing
Basic NHS cost of any secondary dressing
Frequency of dressing change
Expected duration of treatment
Estimated total cost
Please indicate any additional expenditure or savings associated with the requested product
eg. drug treatment or non-drug therapy or procedures
Requested by
Name of Practitioner(s) / Speciality & Organisation / Date / Contact details(Tel no. & e-mail)
For Wound Formulary Group use only - delete options that do not apply
Date request receivedProduct name
Date considered
Wound Formulary Group decision / § Approved for assessment
§ Approved for addition to Formulary
§ Approved to replace another dressing on Formulary
§ Request declined
Approved criteria for use
(including any restrictions) /
Estimated patient numbers /
Agreed assessment period /
Agreed responsibility for prescribing during assessment / § Initiation on recommendation of a TVN only
§ Hospital specialist eg. vascular, plastics, dermatology
§ Initiation by hospital specialist who will prescribe the first month’s supply before referral to general practitioner
§ Practitioners within specific practice/area
Agreed responsibility for patient follow-up / § Hospital TVN
§ Hospital specialist
§ Community TVN
§ District nurse
§ General practitioner
§ Shared responsibility
Date assessment feedback due /
Date assessment feedback presented /
Agreed recommendations/restrictions for future use /
Rationale for decision /
Date added to Formulary dressings list /