Nhs wales policy making decisions on individual patient funding requests (ipfr) application form



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N
HS WALES POLICY MAKING DECISIONS ON INDIVIDUAL PATIENT FUNDING REQUESTS (IPFR)

APPLICATION FORM



COMPLETING THIS FORM:
Before submitting an IPFR, please check you are using the correct process and that this should not be considered via another route such as a referral management system, compassionate drug use etc, that your Health Board may have in place. IPFRs can be submitted by an NHS consultant or GP where he/she will be responsible for delivering/administering the treatment. The requesting clinician is responsible for providing all supporting information and evidence.
If you would like help to complete this form, please don’t hesitate to contact the appropriate IPFR team.


  1. Application Form: Please complete the form electronically, expanding the boxes as required (illegible and incomplete forms will be returned). An unsigned form will not be accepted.

    1. A password protected word version to be emailed as long as signatures are present. Password to be emailed separately or telephoned through. (Password protection only required for emails received outside Wales).

    2. Applications for Specialised Services should be completed by the patient’s secondary care clinician.

    3. Applications for tertiary referrals should be completed by patient’s secondary care clinician unless extenuating circumstances dictate otherwise.

    4. Not every question need be answered for every case; but please signify ‘not applicable’ rather than leaving a blank.




  1. Supporting Evidence: Please also enclose the latest clinic letter(s), relevant evidence and any supporting clinical information you feel is appropriate. Please note however that all pertinent information should be included within the form.




  1. Where to Submit the Form and Supporting Information:




Health Board

Post

Email, Fax & Telephone

Abertawe Bro Morgannwg University Health Board

Individual Patient Care Services Manager, Abertawe Bro Morgannwg University Health Board, 1 Talbot Gateway, Baglan Energy Park, Port Talbot, SA12 7BR

ABM.IPFR@wales.nhs.uk

Fax: 01639 687675

Tel: 01639 683389


Aneurin Bevan University Health Board

IPFR Co-ordinator, Aneurin Bevan University Health Board, Llanfrechfa Grange, Room 43, Llanfrechfa Grange House, Cwmbran, NP44 8YN

IPFR.ABB@wales.nhs.uk

Fax: 01633 623817

Tel: 01633 623449


Betsi Cadwaladr University Health Board

IPFR Team, Betsi Cadwaladr University Health Board, Planning Dept, Glan Clwyd Hospital, Bodelwyddan, LL18 5UJ

BCU.IPFR@wales.nhs.uk

Tel: 01745 448788 ext 7930


Fax: 01745 448 211

Cardiff & Vale University Health Board

IPFR Co-ordinator, Cardiff and Vale University Health Board, Public Health Offices, Whitchurch Hospital, Park Road, Whitchurch CF14 7XBA

CAV.Irt@wales.nhs.uk

Fax: 02920 336235 / 233

Tel: 02920 350612


Cwm Taf University Health Board

IPFR Co-ordinator, Cwm Taf University Health Board, Ynysmeurig House, Navigation Park, Abercynon, CF45 4SN

Cwmtaf.IPFR@wales.nhs.uk

Fax: 01443 744889


Tel: 01443 744821

Hywel Dda University Health Board

IPFR /RMC Manager, Springfield Building

Withybush General Hospital, Fishguard Road

Haverfordwest, Pembrokeshire, SA61 2PZ


hdd.ipfr@wales.nhs.uk

Fax: 01437 772402

Tel: 01437 834486


Powys Teaching Local Health Board

IPFR Co-ordinator, Commissioning Team, Powys Teaching Health Board, Bronllys Hospital, Bronllys, Brecon, Powys, LD3 0LU

monitoring.powyslhb@nhs.net

Fax: 01874 712685

Tel: 01874 712690


Welsh Health Specialised Services Committee (WHSSC)

IPFR Team, Welsh Health Specialised Services Committee (WHSSC), Unit 3a, Caerphilly Business Park, CF83 3ED

whssc.ipc@wales.nhs.uk whssc.ipc@nhs.net

Fax: 02920 869534



Tel: 01443 443 443 ext 8123



PART 1: DETAILS OF CLINICIAN SUBMITTING REQUEST


Details of Clinician making request (must be a GP/ Consultant who is currently providing care for the patient)

Name:




Job Title:




Professional Registration Number:




NHS Health Board, Trust or GP Practice:




Correspondence address:




Tel:




Email:




Secretary’s Name:




Tel:




Secretary’s Email:





PART 2: DETAILS OF PATIENT


Details of Patient

Forename:



Surname:




Address:

(including postcode)


Postcode:




NHS Number:




Date of Birth: (dd/mm/yy)




M or F:




Registered GP or GDP Name and Practice:






PART 3: URGENCY


How urgent is the request and why?

(tick as applicable)

Urgent:

24 – 48 hours



Soon:

3 days – 3 wks



Non-urgent:

4 – 6 wks












If the request is urgent or soon please provide clinical reasons why this needs to be considered outside of panel meeting. Administrative reasons will not be considered.





PART 4: CONFIRMATION STATEMENT BY CLINICAN


I confirm that as the patients Consultant/GP I have discussed this IPFR Application and its process with my patient (and / or their representatives) and I believe that:


  • they have understood what is proposed in this application

  • they are aware that the IPFR Administration Team will retain this application as part of the administration process for IPFR application

  • they understand that the IPFR decision panel will not receive identifiable information and will not be able to identify them from this application

I have explained the process around demonstrating exceptionality and that this case may or may not be approved.


I have discussed what the treatment is likely to involve, the likely benefits and risks of this treatment and any available alternative treatments (including no treatment) and the particular concerns of this patient which I am able to address with my knowledge.
I understand that consent of the patient for the treatment/procedure will be required after full discussion with the healthcare professional responsible for prescribing or providing the treatment. This form should not be regarded as informed consent for the proposed treatment/procedure.
To the best of my knowledge the information I have provided within this document is a true and accurate reflection of the current clinical circumstances of the patient at the time of completion of the form.
I will make myself available, where possible, to provide any clinical advice required on or before the day of the panel to clarify any clinical issues to avoid unnecessary delays to the panel in reaching a decision.

I agree to provide outcome data within a timely manner to the IPFR team on the progress of the patient.


The IPFR Administration Team retains a record of the IPFR application and subsequent decision and any outcome data that is provided by the clinician. Data will be retained to help inform future planning requirements by identifying patient cohorts both at a local and national level. Data will also be used for the production of an annual report on IPFR’s every year as required by the Welsh Government. This will not include any identifiable data and will use aggregated data.



Clinician’s Name(Print):




Clinician’s Signature:




Designation / Job title:




Date:






Please note:
The information included in parts 5 to 10 will be copied and seen by IPFR panel members, therefore do not include/refer to any patient’s identifiable information such as name, age, gender etc within these parts.

PART 5: DIAGNOSIS AND PATIENT’S CURRENT CONDITION RELATED TO REQUEST


Diagnosis:



Has this been discussed by the MDT?

Yes




No




If Yes, please give details and provide documented support of the discussions




Relevant Medical History:




Current status of the patient (complete A or B):




  1. Intervention for cancer:

What is disease status? (e.g. at presentation 1st, 2nd or 3rd relapse)


What is the WHO performance status?




How advanced is the cancer? (stage)




Describe any metastases:



  1. Intervention for non-cancer:

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


Please summarise the current status of the patient in terms of quality of life, symptoms etc:




Summary of previous interventions for this condition:
Reasons for stopping may include:


  • Course completed

  • No or poor response

  • Disease progression

  • Adverse effects/poorly tolerated

Date of Intervention

Nature of Intervention

Reason for stopping/

response achieved

Location that Intervention was carried out










































PART 6: DETAILS OF INTERVENTION RELATED TO REQUEST


Nature of the intervention:

(If combination, tick all that apply)

Drug







Surgical procedure







Medical Device




Therapy




Second opinion




Other




If medical device is required for intervention has it received a CE marking for use within the EU?

Yes  No 
If No, please give details and provide documented support of the reasons



What specific intervention is being requested:




Indication for intervention:



Provider and location of the intervention:




Details of clinician who will undertake the intervention:

Name:




Job Title:





PART 6A: DRUG INTERVENTIONS


Full name of drug and manufacturer:




Planned dose and frequency:




Patient weight or BMI:

(include if dose based on weight/BMI)




Line of treatment:




Has the patient been through all NICE/AWMSG approved regimes:




Planned duration of intervention:




Optimal start date:




If the intervention forms part of a regimen, please document in full:

(e.g. drug X as part of regimen Y (consisting of drug V, drug W, drug X and drug Z)




Drug licensed for requested indication in the UK?

Yes  No 

If No, is it licensed within the:-

EU  USA 



PART 6B: NON DRUG INTERVENTIONS (Surgical procedures, Therapies)


Describe the intervention as it applies to this patient:




Is this intervention listed by the Health Board as an Intervention Not Normally Undertaken (INNU)?

Yes  No 

As an outcome of the request, what is the proposed treatment plan?




Why it is necessary for the patient to be specifically treated at the proposed provider?





PART 6C: TREATMENT OPTIONS


What is the usual treatment pathway?



Why is the patient not following the usual treatment pathway?



What is the alternative treatment intervention?



What are the reasons for not using an alternative intervention strategy?



What are the implications of not receiving the requested intervention?


PART 7: ANTICIPATED OUTCOMES


Please outline any anticipated or likely adverse effects of the requested intervention, including the toxicity of any drug?



How will you monitor the effectiveness of the requested intervention?



What are the criteria for stopping the treatment?



What is the minimum timeframe/course of treatment after which a clinical response can be assessed?





PART 8: STATEMENT OF EXCEPTIONALITY


Please describe as clearly as possible why this patient’s clinical circumstances are exceptional i.e.


  • Why the clinical presentation of the patient is unusual / rare? AND

  • Why does this unusual/rare clinical presentation mean that the patient will derive a greater clinical benefit from the treatment than other patients with the same disease?



Point to Consider

Note that rarity in itself does not constitute exceptionality



PART 9: EVIDENCE OF CLINICAL EFFECTIVENESS


Give details of key studies supporting the use of the requested intervention for this condition:
Please provide references or attach articles




The intervention has been considered for this indication by:

AWMSG  NICE  Not considered 
Other (e.g. SMC, Royal College, Locally Agreed Clinical Pathway) 




Please reference technology appraisal number and specify outcome/status




Points to Consider

  • Are there peer reviewed clinical journal publications available?

  • Is there evidence from clinical practice or local clinical consensus?

  • Has the rarity of the disease been considered in terms of the ability for there to be a comprehensive evidence base available?

  • Service and Policy Implications

  • Does the decision indicate a need to consider policy or service change? If so, refer to service change processes.



PART 10: ECONOMIC ASSESSMENT


What is the cost of the intervention? (inc VAT)
Where appropriate, include here the total cost of the treatment, taking into consideration the patients weight or BMI, any loading does required and the number of cycles applied for. It would be helpful to break down the cost per cycle/month.


If this treatment is part of a regimen / pathway, what is the total cost of the rest of the regimen /pathway to deliver the treatment?
This should include cost for any additional follow up/outpatient appointments.




What is the cost of the alternative interventions or formulary alternative?




Are there any offset costs?

Yes  No 

If Yes, please describe




What is the potential net cost to the health board division, if any?



Points to Consider

Treatment costs may vary significantly based on a patient’s weight/BMI.

Costs included must reflect true costs to the Health Board as the amount of funding agreed will be based on the economic assessment provided within this request. If true costs are higher they will not be funded.







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