Individual Funding Request Application Form

INDIVIDUAL FUNDING REQUEST APPLICATION FORM

On completion, please e-mail to

IMPORTANT GUIDANCE
This form should be read in conjunction with Bedfordshire Clinical Commissioning Group’s Individual Funding Request Policy.
Please note that individual case funding should not be requested where the intention is to introduce a new treatment for a definable group of patients (however small). Such requests should be forwarded for consideration by the Bedfordshire Clinical Commissioning Group’s Prioritisation Panel using the appropriate proforma for the introduction of new treatments.
The purpose of the Individual Funding Request process is to provide a mechanism for considering the needs of individual patients whose personal circumstances might make them exceptional or individual patients within the terms of the Individual Funding Request Policy.
This proforma is designed to facilitate the full and fair consideration of each Individual Funding Request. It should be completed in full in respect of each patient for whom such a request is made. Please also submit any additional information that you wish to be taken into consideration.
Please note that the Individual Funding Request process cannot be used to make policy decisions on behalf of the Bedfordshire Clinical Commissioning Group. The Individual Funding Request process cannot make a decision to fund a patient where by so doing a precedent would be set that establishes new policy (because the patient is not, in fact, exceptional but representative of a definable group of patients). If you are uncertain as to whether the Individual Funding process or a policy decision through the Prioritisation Panel is more appropriate, please discuss with the Bedfordshire Clinical Commissioning Group’s Strategy and System Redesign Directorate.
Please note that the panel requires all information submitted to be anonymised, the maximum identifiers should be: NHS Number; Gender; Age; GP; to protect patient confidentiality and ensure panel objectivity.
Any request submitted without a fully completed application form, the relevant supporting information and clinical evidence, will be returned.

For treatments subject to NICE TAGs (and are PBR excluded) or those subject to local policies, please only complete Sections 1 & 2.

Fully completed application forms should be saved locally and sent from a secure NHS.net account to for consideration. If you are having difficulties finding the information you require please call 01494 555530 where a member of the IFR service will assist you.

SECTION 1CONTACT INFORMATION

Date of Completion of Request:
Requesting Organisation (e.g. Hospital Trust / GP Practice)
Address:
Applicant Details:
Name:
Designation:
Tel:
Email:
Person to contact in case of queries:
Patient Details:
Initials:
Hospital ID number:
NHS number:
DoB:
Registered Consultant:
Registered GP name:
Registered GP address
Referred by (other than GP):
Date of referral:
How urgent is this request?
(please select one)
All requests will be dealt with as routine unless another option is selected. / □Most urgent [1]– Decision needed within a week as the patient’s life may be in danger
□Soon – Decision needed within 3 weeks as delay will not be clinically appropriate
□Routine – Decision needed within 4 to 6 weeks

SECTION 2INTERVENTION REQUESTED

Patient Diagnosis including objective measures of severity (for which treatment is requested):
Incidence and prevalence of the condition (for which the treatment is requested):
Name of drug(for which funding is requested):
Dose and frequency:
Length of treatment:
Route of drug administration:
Does the drug have a product licence in the UK for the indication requested: / YES / NO(please delete as appropriate)
What is the NICE TAG relevant to the application(if applicable):
Anticipated cost (inc. VAT): / £
Activity cost/code associated with the treatment: / £
Summary of previous treatment(s) this patient has received for this condition and reasons for stopping/response achieved. (Please include start and stop dates)
Start Date / Drug/Treatment / Reasons for stopping and stop date/response achieved
Has the treatment already been initiated due to patient circumstances? Delete as appropriate: Yes / No
If Yes, please give details as to why:

SECTION 3EXCEPTIONALITY

Please confirm that the request is not about introducing a new therapeutic treatment of benefit to a definable group or sub-group, however small.

YES – it would be of benefit to a similar group or sub-group of people

NO – it would not generally benefit others with this condition; this case is different

Evidence of exceptionality must be provided in all cases except where the patient’s circumstances fall within paragraph 6.4 of this policy.

If no evidence of exceptionality is provided, this request will be treated as a service development and considered through Bedfordshire Clinical Commissioning Group’s Prioritisation Process. A business case will need to be completed by the provider.

If you can answer “no” to the question above, please complete the following:

Please tell us how this patient is significantly different to the general population with the same condition in question and attach supporting evidence
Please tell us why this person is likely to gain significantly more benefit from the treatment than might be expected from the average patient with the same condition and attach supporting evidence
Any other comments/Supporting information

SECTION 4CLINICAL EFFECTIVENESS AND COST EFFECTIVENESS

PLEASE COMPLETE AS FULLY AS POSSIBLE

1. Is requested drug part of a clinical trial? Delete as appropriate: Yes / No If Yes, give details (e.g. name of trial, is it an MRC/National trial?)

Is the drug funded through a clinical trial? Delete as appropriate: Yes / No
2. (a) What would be the standard drug or treatment regimen be at this stage?
2.(b) What is the cost of the drug and how does this compare with the cost ofthe standard therapy it replaces? Please ensure you include all attributable costs that are connected to providing the treatment/procedure e.g. drug/staff/follow up/diagnosis etc.
2.(c) What would be the expected outcome from the standard drug/treatment regimen?
2.(d) What are the exceptional circumstances that make the standard drug treatment regimen inappropriate for this patient?

1. What is the patient’s clinical severity? (Where possible use standard scoring systems e.g. WHO, DAS scores, walk test, cardiac index etc.)

1. Has the Trust Drugs and Therapeutics Committee or equivalent Committee approved the requested treatment for use? (if drug or medical device)

Delete as appropriate: Yes / No
If No, Committee Chair or Chief Pharmacist approved: Yes / No

1. Give details of National or Local Guidelines / recommendations or other published data supporting the use of the requested treatment regime for this condition?

If you are citing clinical evidence in support of this request, please indicate the level of evidence as follows:
PUBLISHED[2] trials/data please forward papers / web links for peer-reviewed papers.
6.(a) Evidence from: meta-analysis of RCTs or at least two good quality RCTs.
6.(b) Evidence from one good quality RCT and supporting non-randomised (phase II) trials.
6.(c) Evidence from lower quality RCT (s) and/or more than one phase II study and/or good quality observational studies.
6.(d) Evidence from single phase II study, case studies etc.
6.(e) Expert opinion
7. (a) How will you monitor the effectiveness of this treatment regimen?
7.(b) What would you consider to be a successful outcome for this treatment regimen in this patient?
8. What is the anticipated Cost/QALY and/or cost benefit for this treatment regimen?
9. What is the anticipated toxicity of the treatment for this patient?

ALL REQUESTS

CONSENT
The patient should be kept fully informed of progress of their request unless it contains information that would be detrimental to their condition. This should be by the most appropriate method with respect to their individual needs. By submitting this request, you are confirming that you have fully explained to the patient the proposed treatment and that they have consented to you raising an Individual Funding Request on their behalf, and that you will ensure communication with the patient as individually appropriate.
Signature of
Requesting Clinician…….…………………………………………………………………………...
Date…………………………….
Application reviewed by Chief Pharmacist or nominated deputy e.g. relevant directorate pharmacist (in the case of a drug treatment) / Name:
Signature or email confirmation:

Please include with your request:

• Evidence demonstrating why you feel this patient is an exceptional case
• Supporting/referral letters from other organisations/consultants involved in the patient’s treatment (if applicable)
• Evidence based documentation regarding the efficacy of the treatment proposed.

Individual Funding Request Application FormPage 1

[1] For treatments that are urgently required, where significant harm may occur through delay, it must be provided to the patient and retrospective approval for funding should be sought.

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