LAPAROSCOPIC VENTRAL RECTOPEXY AND STARR

Application for Prior Approval OF Funding

STRICTLY PRIVATE AND CONFIDENTIAL

PART A: THIS PAGE MUST BE COMPLETED FOR ALL REQUESTS

PATIENT INFORMATION
Name / Male / Female
Address
Post Code
Date of Birth / NHS Number
Referrer’s Details (GP/Consultant/Clinician):
Name
Address
Post Code
Telephone / Email
GP Details (if not referrer):
Name / Practice
By submitting this form you confirm that the information provided is, to the best of your knowledge, true and complete and you confirm (please clarify in the box below) that you have:
·  Discussed all alternatives to this intervention with the patient.
·  Had a conversation with the patient about the most significant benefits and risks of this intervention.
·  Advised the patient that NHS Decision Making Aids are available online should the patient wish to access them at http://sdm.rightcare.nhs.uk/pda/
·  Informed the patient that this intervention is only funded where criteria are met or exceptionality demonstrated.
·  Checked that the patient is happy to receive postal correspondence concerning their application.
·  Discussed with the patient whether any additional communication requirements (e.g. different language, format or limited capacity) are needed (please specify requirements in the box below).
ANY REQUESTS NOT COUNTERSIGNED BY A SENIOR CLINICIAN/Salaried
or Partner GP WILL BE RETURNED.
Clarification/Communication Needs:
I understand that it is a legal requirement for fully informed consent to be obtained from the patient (or a legitimate representative of the patient) prior to disclosure of their personal details for the purpose of a panel/IFR team to decide whether this application will be accepted and treatment funded. By submitting this form I confirm that the patient/representative has been informed of the details that will be shared for the aforementioned purpose and consent has been given.
SIGNED REFERRER: ………………………………….….………………… DATE: …………………..

PART B: THIS PAGE MUST BE COMPLETED FOR ALL REQUESTS

If your patient does not meet the following criteria then please ALSO fill out Part C of this form outlining

the patient’s exceptionality. If the criteria are met you only need complete Parts A and B.

NOTE: Treatment for full thickness prolapse can often present as an emergency. Funding approval for this is NOT required.
1.  Has the patient been considered by a Multidisciplinary Pelvic Floor Team, consisting of a Gynaecological Surgeon, a Colorectal Surgeon and Pelvic Floor Physiologists*?
* this MDT will not be quorate unless a representative from each of these groups is present.
AND
2.  Has the Multidisciplinary Team (MDT) confirmed that:
·  they recommend this treatment for this patient over all alternatives?
·  the potential benefit outweighs potential harms?
·  the MDT is satisfied that the necessary capacity and expertise available to handle this intervention is in place in the proposed delivery setting?
AND
3.  Has conservative management been tried and failed, including a selection of the following as appropriate for the individual: Dietary advice; pelvic floor exercises; osmotic and stimulant laxatives; bulking agents and antispasmodics; glycerine and bisacodyl suppositories and biofeedback?
AND
4.  Does the patient have unresolved faecal incontinence or obstructed defecation syndrome?
AND
5.  Have the risks, benefits, and side effects of the procedure been discussed with the patient, and the patient wishes to be considered for this treatment? / YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Please provide the relevant Primary Care Consultation Records with clinic letters (if appropriate) to support the information you have provided.
Without evidence this application will be rejected.
Supporting Information
Please document the evidence you are enclosing along with any other information that you feel is relevant

pLEASE SEND THIS FORM TO THE CCG IF THE ABOVE CRITERIA ARE FULLY MET AND EVIDENCED. IF NOT, PLEASE GO ON TO COMPLETE PART C.

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Part C: INDIVIDUAL FUNDING REQUEST

Only Complete if Patient DOES NOT MEET THE CRITERIA IN PART B

Exceptionality / Please note that not meeting the criteria is not in itself exceptional. The sections below must be completed, clearly outlining a comprehensive and thorough case for the exceptionality of your patient, to enable the IFR Panel to reach a funding decision.
Explain why the patient is significantly different to the general population of patients with the condition in question
Explain why the patient is likely to benefit more from the intervention than might normally be expected for patients with that condition
Brief and relevant health history, including patient’s current health status and any other co-morbidities, health issues and current medication.
Clinical History
relevant to the case
What treatments has the patient tried? Is this patient unable to tolerate the usual care? What services has the patient been referred to?
The completed form should be sent in confidence with any other supporting documents to:
North Somerset CCG
By email to:
By post to:
Referral Support Service
Post Point 11
Clevedon, North Somerset
BS21 6FW / Bristol CCG / South Gloucestershire CCG
By email to:
By post to:
Individual Funding Request Team
Suite 15, Corum 2
Corum Business Park,
Warmley, South Gloucestershire, BS30 8FJ
In order to comply with information governance standards, emails containing identifiable patient data should only be sent securely, i.e. from an nhs.net account.

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