INDIVIDUAL FUNDING REQUEST (IFR)

EXCEPTIONAL FUNDING REQUEST FOR COSMETIC SURGERY

Please note that Cosmetic Breast Surgery is not funded. There is no evidence that cosmetic breast surgery will resolve psychological symptoms only which arise from the size and/or shape of the breast. An exception may be made if the patient meets the criteria below and the exceptionality is clearly demonstrated on the second page.

Please tick to answer the following questions in conjunction with the criteria supplied and return to:-

Individual Funding Request (IFR) Team, Central Southern Commissioning Support Unit, 2nd Floor Bath Road, 57-59 Reading, Berkshire, RG30 2BA email:

PLEASE NOTE THAT UNLESS THE PATIENT FULLY MEETS THE CRITERIA AND 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.

GP/CONSULTANT’S DETAILS
Name:
Address:
PATIENT’S DETAILS
NHS No:
Patient ID:
ESSENTIAL CRITERIA (please circle yes or no)
1.  Does the patient have a Body Mass Index (BMI) of 30 or below?
PLEASE STATE THE PATIENT’S BMI: / YES / NO
2.  What is this patient’s
a) Height? b) Weight?
3. Has the patient maintained their BMI/weight for at least 2 years?
/ YES / NO
4. Procedure being requested:
Except in the case of the genital area, please provide photographic evidence to support the patient’s application. Cases will not be considered without photographs.
5. Is there compelling evidence of psychological distress, social distress, or adverse physical health effects e.g. infection on this patient?
IF YES, PLEASE PROVIDE AN EXPLANATION:- / YES / NO
6. Is there a reason to believe that corrective surgery will lead to an improvement in health status for this patient?
IF YES, PLEASE PROVIDE EXPLANATION / YES / NO
7. Details of any treatment already received for the same condition.

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:

Ø  Significantly different to the general population of patients with the condition in question

and

Ø  likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition.

However:

Ø  The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception.

Ø  If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional.

Ø  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.

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Central Southern Commissioning Support Unit April 2014