IFR Application Form

							REF:



       Application form
                                   Individual Funding Request Panel
       Application for treatments not normally funded by NHS Gloucestershire and Swindon i.e.
       treatments for patients with exceptional clinical circumstances to current treatment policy or
       individual request for experimental treatment.

       Notes for completion

       Further information about the application process is provided in the Protocol for the
       consideration of ‘Exceptional Treatment’ referrals available on the NHS Gloucestershire
       website: www.nhsglos.nhs.uk

       1.   In making a case for individual funding request it needs to demonstrate that
                  the patient is significantly different to the general population of patients with
                     the condition in question; and

                      the patient is likely to gain significantly more benefit from the intervention than
                       might be normally expected for patients with that condition.

       2.   All areas must be completed electronically.

       3.   It is the responsibility of the Clinician to detail sufficient clinical evidence in the
            application and to provide hard copies of research or other documentary evidence to
            support the application.

            Applications without supporting information will be returned to the Clinician, and will not
            be considered by the Panel.

       4.   For secondary and tertiary care applications: All treatment requests must be
            approved by the Chief of Service or Specialty Director.

        I confirm that I have fully discussed this application with my patient.

        Managing clinician
        PRINT Name:

        GMC registration no:

        Address:


        Date:

        Secondary and tertiary care applications only.

        Agreed and authorised by the Chief of Service or Specialty Director

        PRINT Name:

        Signature/email confirmation of authorisation:
1. Patient’s details
Name                                                              NHS Number
Address



D.O.B.
GP Name
GP Surgery

2.   Brief history including patient’s current health status and any other relevant health
     care problems




3.   Summary of previous interventions this patient has received for this condition




4.   Details of the treatment/equipment for which funding is requested




For drug requests, please state if it is licensed for this indication     Yes        No
Discussed in MDT                                                          Yes        No
Outcome of meeting:




Has this been agreed with the Trust Prescribing Lead                      Yes        No
5.   What are the intervention goals and expected outcomes following treatment?




6.   Is any alternative treatment/equipment available? Is this alternative commissioned
     by NHS? Why is this alternative not appropriate for the patient?




7.   Proposed provider of the treatment (include any alternative providers, if appropriate)




8. Cost (if information is available) and length of treatment (if known)
Cost (£)
Length of Treatment
Preferred start date (and reason):
9.   Evidence that the treatment proposed has the potential to result in health
     improvement for the patient, including recent evidence of effectiveness/NICE
     guidance etc.

     (A policy not to commission a service/therapy usually reflects a lack of evidence of
     effectiveness, or evidence of limited benefit balanced against adverse effects.
     Please provide details of research/clinical evidence that supports this particular
     application).




10. Implications for the patient if proposed treatment is not funded




11. Proof of ‘Exceptionality’ - rationale for bringing this case to the Individual Funding
    Request Panel

     For applications to fund cosmetic problems, accompanying photographic evidence
     is also requested.

     (NB It is the applying clinician’s responsibility to obtain consent from the patient for
     photographic evidence to be used for this purpose.)
 12. Are there likely to be other similar patients?   Yes   No


 13. Patient’s submission in support of their case:
 Has this patient been made aware this application is being      Yes      No
 made?
 Has the patient been asked to submit accompanying               Yes      No
 information in support of their case?
 If so, is the submission:             attached to this     being provided
                                       application, or      separately

Communication of the decision

It is NHS Gloucestershire and Swindon policy to communicate the decision of the
Panel to the referring clinician, with a copy to the patient’s GP (unless otherwise
advised), therefore please discuss the outcome of this application with your patient.



The completed form should be sent with any other supporting documents
electronically or by post, to:

                 Andrea Powell
                 IFR/INNF Coordinator
                 NHS Gloucestershire
                 Sanger House
                 5220 Valiant Court
                 Gloucester Business Park
                 Gloucester GL3 4FE       Fax: 08454 221853 (Safe Haven)
                                          Tel: 08454 221542

                 g-pct.IFR-glosandswindon@nhs.net