Individual Funding Request Proforma
Secondary Care Clinicians
This proforma is to be completed by clinicians acting on behalf of their patient to request funding
from NHS Worcestershire for individual funding of drugs or therapeutic interventions not
routinely commissioned by that PCT.
Please note, if this request relates to oncology treatment, we request a response within 3
working days to meet the national targets.
To minimise delays in the application process please ensure ALL fields are completed
comprehensively. Incomplete forms or forms with insufficient levels of information will be returned
to the requesting clinician and may result in a delay in the request being considered.
Important information regarding INDIVIDUAL FUNDING REQUESTS:
Before you being to complete this form and make an application you MUST first consider the
following question.
Are there likely to be any other patients with similar clinical circumstances in Worcestershire
who may also benefit from the treatment you are requesting?
If the answer is YES then this is an inappropriate way to request funding. The contract which has
been agreed between PCTs and your Trust requires the service provider to seek funding through
the submission of a business case. This is because the case represents a service development for
a predictable population. You should discuss with your contract team how you submit a business
case for consideration through the annual prioritisation round.
If the answer is NO and you can provide evidence for why this is the case then please proceed by
completing the application below. You must also ensure your trust has agreed to you submitting this
request.
This form should not be used to request funding for
 NICE TAG approved treatments and/or technologies for specific indications
 Treatment requiring prior authorisation
 Consideration of potential service developments (see above)
 Approved indications where funding is already sanctioned under an existing commissioning
policies and where the patient meets the treatment criteria.
For guidance on whether this is an individual request or an exceptional request for requesting
clinicians, please refer to Appendix 1
Treatment being
requested
Patient Details:
Patient Name:
Patient Address:
Patient Date of Birth:
Patient NHS Number:
GP Name:
GP Practice Name:
Decision to Treat Date
Please confirm whether
For oncology treatment requests, please provide the decision to treat
date for this requested treatment .i.e within the 31 day target.
the patient has
consented to treatment
before this request was
submitted
Does the patient
provide consent for all
information regarding
their case to be shared
with NHS
Worcestershire’s
Screening and IFR
Panel?
YES/NO
Provider Details:
Name of Requesting
Provider Trust:
Name of Requesting
Clinician:
Telephone Number:
Secretary’s Contact
Details:
Email Address:
Request Date:
Have you sought the
approval of your
contract team to make
this request?
From whom did you
seek agreement?
YES/NO
Please provide contact details:
Provider contract teams need to satisfy themselves that this is not
a service development request and a breach of clause 38.8 of the
NHS Contract before making this request
Request Details:
Background on
individual patient’s
condition:
Diagnosis and History:
Outline the patient’s clinical situation, including current diagnosis, the
severity and duration of the symptoms, the nature of ongoing
symptoms and the impact of the condition on the patient’s well being.
Treatment and Outcome:
Please outline any treatment received to date (non-pharmacological,
pharmacological, non-surgical/surgical), the dates of each treatment
and the outcome in chronological order.
For oncology treatment, please indicate previous therapies received to
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Request Details:
treat this condition.
Please ensure you provide clear, chronological, evidence of all
treatments received, including the number of cycles of each treatment
where possible and the outcome of each treatment received.
Usual management of
this condition:
Details of standard NHS treatments this requested treatment will
replace (if any)
About the requested
treatment:
What is the proposed treatment, including the following:
 How will it be used?
 Course of treatment duration?
 Planned duration of treatment
 One off or recurrent courses
 Anticipated benefits of using this treatment (and degree of
confidence of the Clinical Team that these outcomes will be
delivered for this patient)
 Potential significant adverse effects/risks
 Monitoring plan
Alternative
Management Options
for this Patient:
If this request is declined, what treatment will this patient receive?
Evidence to support
requested treatment:
Supportive Research:
Please provide additional research information to support this
application, include references or preferably copies of any clinical
research materials which supports or contributes to this request.
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Request Details:
Patient Exceptionality:
If you wish NHS Worcestershire to consider this application on the
grounds of patient exceptionality, please provide details here, i.e. why
is this patient substantially different to the general population of
patients with this condition, such that they would benefit more from this
treatment/therapy than any other patient?
Please refer to Appendix 1 for guidance.
National and
International Guidance:
Has this treatment been considered by NICE or any other
national/international agencies?
Please provide reference details, e.g. TAG references, where possible.
Local guidance:
Has your Host Commissioner (PCT) developed a local policy regarding
this treatment that we may review? If so, please provide a copy.
Additional
Views/Comments made
by requesting clinician
in support of
application:
Estimated treatment
costs (per course of
treatment and/or per
annum where most
applicable to this case):
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Request Details:
Potential patient
numbers:
What is the incidence for this condition?
For example, the number per 100,000 population.
Declaration:
To the best of my knowledge I have given the most accurate and up to date information
regarding this patient’s clinical condition.
Name:
Position/Title:
Signature:
Date Completed:
Please email with supporting information to:
[email protected]
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Appendix 1
Guidance for the clinician making the request for consideration
If this is an Individual Request
Guidance
Almost all of these requests will relate to experimental treatments: either a request to
access an experimental treatment, enter a patient into a trial or to use a treatment offlabel for a rare clinical condition or situation.
For requests to enter patients into a trial (whether to fund to enter the trial or pick up
post trial funding) – the key questions are:
1. whether or not the trial is strategically important for the programme area
2. whether or not all the trial data will be in the public domain
3. whether or not the trial protocol is robust (e.g. can assess improvements in
important clinical outcomes)
The trial protocol will need to be forwarded with your application.
For off label use for rare clinical circumstance the key questions are:
Is there evidence of cost effectiveness for this treatment? It is biologically plausible
that this treatment will work in this clinical situation?
Where the treatment is a drug please indicate its UK license status.
Your application needs to include the following additional information:
1. A comprehensive and balanced clinical picture of the history and present
state of the patient’s medical condition,
2. The nature of the treatment requested and the anticipated benefits of the
treatment and any significant adverse effects.
3. The degree of confidence of the Clinical Team that the outcomes will be
delivered for this particular patient.
4. The previous treatments/interventions this patient has received for this
condition and the outcome of these for the patient.
5. Details of NHS standard NHS treatment this requested treatment will replace
if any.
6. The expected benefits and risks of treatment.
The Clinical Team shall refer to, and preferably include, copies of any clinical
research material which supports, questions or undermines the case that is being
made that the treatment is likely to be clinically effective in the case of the individual
patient
Include any additional material.
The relevant commissioning policies are:
Individual Funding Request Operating Procedure
WM/1 ‘Ethical Framework to underpin priority setting and resource allocation
within collaborative commissioning arrangements’
WM/9 ‘Individual funding requests’
WM/14 ‘Experimental and proven treatments’
NICE IPG guidance where this exists.
http://www.worcestershire.nhs.uk/publications/policies-andprocedures/commissioning.aspx
In all cases affordability and relative priority compared to other unfunded
development remain key considerations for the responsible PCT.
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Appendix 2
Guidance for the clinician making the request for consideration
If this is an Exceptionality Request
Guidance
An exceptionality request is only relevant where there is an existing general or
treatment specific policy and where the responsible commissioner has already taken
the decision not to fund either the treatment or some categories of patients or NICE
have already taken the decision not to approve either the treatment or some
categories of patients for the request you are making
The key question that has to be addressed under these circumstances is on what
clinical grounds can the PCT justify funding this patient when other patients with the
same condition will not?
In making a case therefore the clinician must specify how this patient is clinical
different from others currently excluded from treatment – either in reference to the
clinical picture or the expected benefit or both.
Please note that if there are similar patients the request essentially represents a
request for a policy variation to be made – i.e. expand access to a subgroup of
patients and as such should be treated as a service development and the IFR process
not used.
Your application needs to include the following additional information:
1. A comprehensive and balanced clinical picture of the history and present state
of the patient’s medical condition,
2. The nature of the treatment requested and the anticipated benefits of the
treatment.
3. the degree of confidence of the Clinical Team that the outcomes will be
delivered for this particular patient.
4. Previous treatments/interventions this patient has received for this condition
and the outcome of these for the patient.
5. Details of NHS standard NHS treatment this requested treatment will replace
if any.
6. Expected benefits and risks of treatment.
The Clinical Team shall refer to, and preferably include, copies of any clinical research
material which supports, questions or undermines the case that is being made that the
treatment is likely to be clinically effective in the case of the individual patient
Include any additional material.
The relevant commissioning policies are:
Individual Funding Request Operating Procedure
WM/1 ‘Ethical Framework to underpin priority setting and resource allocation
within collaborative commissioning arrangements’
WM/9 ‘Individual funding requests’
WM/14 ‘Experimental and proven treatments’
NICE IPG guidance where this exists.
http://www.worcestershire.nhs.uk/publications/policies-andprocedures/commissioning.aspx
In all cases affordability and relative priority compared to other unfunded development
remain key considerations.
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