Appendix6:IFRApplicationForm

NHSBlackburn withDarwen CCGNHSChorleyandSouthRibbleCCGNHSEastLancashireCCG

NHSFyldeand WyreCCGNHS GreaterPreston CCGNHSLancashireNorth CCGNHSWestLancashireCCG

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Appendix6:IndividualFundingRequest(IFR)ApplicationForm

Allsectionsof the formmustbe completedotherwise the casewillnotbe consideredImportantinformation

This isformis anappendix to thecollaborativeIndividualFundingRequest processfor LancashireClinicalCommissioning Groups. The fulldocumentmustbe considered beforemaking anapplicationon behalfof a patient to ensure thatitisappropriate.

Before you begin tocompletethisform to make anapplication you MUSTfirstconsiderthe followingquestion:Are theresimilarpatientswithsimilar clinicalcircumstanceswho could also benefitfromthe treatmentyouare requestingacross thepopulation of theCCGs?

If the answerisYES thenmaking anindividualfundingrequestis aninappropriatewayto dealwithfundingforthispatient. Thisis because thecase represents a service developmentfor a predictablepopulation.You should discusswithyourcontract team(orcommissioningleads at the CCG) tounderstand howyou submit a businesscase forconsideration through the usualbusinessplanningprocess.

If the answerisNOthen please proceed bycompletingthe application,providingthe information andrelevantevidence fortheappropriatecategoryofIFRintowhich thispatient’s case falls.

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Mandatoryfieldif proceedingwiththe IFR
Are therelikelytobesimilarpatientsin yourservicein the nextyearwhowillreceivethe sameexpected benefitsfromthistreatmentorintervention?
Yesor no (pleasedelete)
IfYES,pleaseindicatelikelynumberofpatientsthere are likelybenefitfromthistreatmentpermillion population.Ifyoudo nothave thistype ofinformation,pleaseadvise howmanycases youwould expectto refertoaCCGperyear.
MLCSUuseonly
Case code: / Datereceived:
Dateassessed byIFRTeam: / Decision:
IFRscreeningstage date: / Decision:
IFR Panel date: / Decision:
Mandatoryfield
1.Requesting clinician or specialistdetails
Theapplication formshould becompleted bytheclinician responsiblefortheserviceor deliveryofthetreatmentwhohasthe knowledgetounderstandif a patient isexceptionaltocommissioning policyorcurrent contracts.
Thiswould usually bea specialistclinician.
Nameoforganisation:
Name designation ofrequesting clinician:
Address:
Telephone no:
EmailAddress:

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Mandatoryfield
2.Patientdetails
*Forename: / NHS number:
*Surname: / Hospitalnumber:
Dateofbirth: / Gender:
Patient’spersonalemail:
(Thisisrequired forthe patient to receivea copyofemailcorrespondence)
*Patient’saddresspostcode: / Ethnicity:
Pleasenotethat thenecessarypersonalidentifiableinformationshownby* willberemovedfromthisformpriortobeing forwarded to IFRReviewersby the IFR Teamandthedate ofbirth willbechangedtoanage beforebeing forwarded.
Mandatoryfield
3.Patientconsent
Doesthe patient,ortheirauthorised representativeprovideconsentforallinformation regardingtheircase tobe sharedwiththe IndividualFundingRequestPanels? / YES /NO
If the patienthasbeen assessed as nothavingmentalcapacity togive informedconsent,then pleaseconfirmthatyou havecomplied withthe MentalCapacityAct2005and the accompanyingCode ofPractice. / YES /NO
Iconfirmthatthe patientconsents to the use oftheirpersonalemail tobeincluded inanycorrespondence fromIFR Services.
Ifthisis notprovided thencorrespondence willbe postedto the patient’saddress / YES /NO

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Mandatoryfield
4.RegisteredGP details
NameofregisteredGPpractice:
RegisteredGPpracticeaddress:
RegisteredGP:
Telephone no:
Emailaddress:
Mandatoryfield
5.Clinicalurgency
Clinicians are advisedtoread Section 7to understand howurgentapplicationsare defined and managed.
If thisrequestisurgent inaccordancewith Section 7 of thecollaborativeIndividualFunding RequestprocessforLancashireClinicalCommissioningGroups,then anIFRCaseManager (orIFRTeammember)mustbe phonedto advisewhythereis urgency,and howurgentitisto ensure thiscase isgiven the appropriatepriorityand thiscompletedformmustbe submittedto commence the process.The phone number isat the end of thisform.
Mandatoryfield
6.Treatmenthistory
Detailsofdiagnosisprognosis(forwhichthe treatmentisrequested):
Relevantmedicalhistory:
(include dosage andfrequencyofallmedicationsand co-morbidities)

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Previoustreatments/interventionsthispatienthasreceivedforthiscondition: / Date/s / Intervention (e.g.drug. surgery) / Reason forstopping/ Responseachieved
Mandatoryfield
7.Treatment Requested
Informationcan beappended withyoursubmission to supportyoursubmission, egpublishedtrials.
Detailsofintervention/treatmentforwhichfunding isrequested: / Nameoftreatment/intervention:
Describe detailsoftreatment/intervention,egdrug,dose frequency,duration totalnumberoftreatments:
Statusof thetreatment/intervention / Describe thestatusof theintervention eg a UKlicensedmedicine tobeusedwithinthe productspecification,ortobeusedoutside theproductspecification,aninnovative device orappliance,a productunderresearch,a NICEinterventionalprocedure.
Costoftreatment: / Costof the treatment:
Detailofassociatedcosts:(includingVAT AssociatedInpatient /OutpatientActivity):
Anticipatedtotalcost:

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Efficacyof thetreatment/intervention: / Describe theintended benefitforthispatient:
Describe the evidencethatdeliversthe healthbenefit:
Patientsafety: / Describetherisksor safetyprofile forthe treatmentorintervention in thispatient:
Mandatoryfield
8.Alternative treatments
Whatstandardtreatmentdoesthisrequestreplace?
Why isthe standardtreatmentnotappropriate?
Whatwould be thecost of thestandardtreatment?
If thistreatmentrequestisnotapproved,whattreatmentwill begivento the patient?

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Mandatoryfield
9.Request totreatthispatient as anexceptionto a clinicalcommissioningpolicyor equivalent
Whereknown,pleasestatewhichclinicalcommissioningpolicyorpoliciesthisIFRrelatesto:
Pleasesetoutbelow thecaseforthispatientbeingconsideredanexceptionwithreferenceto:
  • whythe patient inquestionis different to the usualpopulation ofpatients towhomthecommissioningpolicyapplies
  • whythatdifferencemeansthe commissioningpolicyshould notapply.
  • anyothermaterialfactorswhichhavebearingonthecase;

Pleaseattachevidenceinsupportofthebenefitoftreatmentinthispatient.Pleaseprovidealistofyourenclosuresbelow:

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Mandatoryfield
10.Declaration
TothebestofmyknowledgeIhavegiventhemostaccurateanduptodateinformationregardingthispatient’s clinicalcondition.
Name
Position/title
Signature
Providertrustsupportforthe application
Name
Position/title
Signature
Datecompleted

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