Application for Prior Approval for Funding for Abdominoplasty and Removal of Loose Skin

INDIVIDUAL FUNDING REQUEST APPLICATION STRICTLY PRIVATE AND CONFIDENTIAL ALL PAGES MUST BE COMPLETED FOR EVERY REQUEST

This form must be completed when applying for treatments that are not normally commissioned by Bristol, North Somerset or South Gloucestershire (BNSSG) CCGs. Please refer to the Interventions Not Normally Funded Lists (INNF) before making an application.

PATIENT INFORMATION Does this case need to be (An urgent request is one which requires urgent consideration and a reviewed urgently due to decision because the patient faces a substantial risk of significant harm or clinical need? YES death if a decision is not made before the next scheduled monthly If yes, please explain meeting of the IFR Panel. What is the window of opportunity and the NO timescale required for optimum treatment?)

Name Male Female

Address Post Code

Date of Birth NHS Number

Referrer’s Details (GP / Consultant / Clinician):

Address Post Code

Telephone Email

GP Details (if not referrer)

Name Practice

By submitting this form you confirm that the information provided is, to the best of your knowledge, true and complete and you confirm (please clarify in the box below) that you have:  Discussed all alternatives to this intervention with the patient.  Had a conversation with the patient about the most significant benefits and risks of this intervention.  Advised the patient that NHS Decision Making Aids are available online should the patient wish to access them at http://sdm.rightcare.nhs.uk/pda/  Informed the patient that this intervention is only funded where criteria are met or exceptionality demonstrated.  Checked that the patient is happy to receive postal correspondence concerning their application.  Discussed with the patient whether any additional communication requirements (e.g. different language, format or limited capacity) are needed (please specify requirements in the box below). ANY REQUESTS NOT COUNTERSIGNED BY A SENIOR CLINICIAN OR A SALARIED/ PARTNER/ LOCUM GP WILL BE RETURNED

Clarification/Communication Needs:

I understand that it is a legal requirement for fully informed consent to be obtained from the patient (or a legitimate representative of the patient) prior to disclosure of their personal details for the purpose of a panel/IFR team to decide whether this application will be accepted and treatment funded. By submitting this form I confirm that the patient/representative has been informed of the details that will be shared for the aforementioned purpose and consent has been given.

Acute Trusts / Providers only: I have attached the relevant meeting minute relating to the application It is essential that appropriate governance systems are in place before an Individual Funding Request is made for a new intervention for the requested indication. Providers and Acute Trusts must therefore confirm that this intervention has been considered by their Clinical Effectiveness/ Drugs & Therapeutics Committee (or equivalent) which supports this intervention as appropriate.

Version: Jan 2018 v1617.1.02 Page 1 of 5 SIGNED REFERRER: ………………………………….….………………… DATE: ………………….

What intervention Q1 are you requesting?

Is this intervention on Q2 the INNF list? YES (a) If no, explain why you are making an NO Individual Funding Request. Are you applying on If yes – please explain how your patient does not meet the CBA (b) an exceptional basis YES criteria: for a Criteria Based Access (CBA) policy? NO

(please refer to the CCG website if further information is required on referral routes)

What is the standard Q3 care pathway for your patient’s condition? Are any alternative Describe Q4 treatments / (a) equipment YES available? NO

Why is this alternative not appropriate? (b) If yes, is this alternative YES commissioned? NO

Please provide details and duration Q5 of proposed intervention

Please provide costs of proposed intervention if known, Q6 including administration of intervention

Expected patient Q7 benefit of proposed intervention

Version: Jan 2018 v1617.1.02 Page 2 of 5 Q8 What will be the (a) impact of refusal on the patient?

(b) How will this be managed if funding is refused?

CLINICAL HISTORY RELEVANT TO THIS CASE

Q9 (a) Brief relevant health history

(b) Current health status

(c) Clinical need

TREATMENT HISTORY RELEVANT TO THIS CASE

What treatment has Q10 the patient tried? (a) What service(s) has the (b) patient been referred to and with what effect?

COHORT How many patients with this condition Q11 would you expect to see per annum in a (a) population of one million?

Would this cohort of patients all benefit YES (b) from this intervention? Provide details NO

How severe is your patient’s condition in (c) relation to this cohort? It is crucial that you answer this question comprehensively; EXCEPTIONALITY OF THIS PATIENT otherwise the panel will be prevented from considering this application fairly.

Version: Jan 2018 v1617.1.02 Page 3 of 5 Why should this Q12 patient’s case be treated as exceptional (a) over and above other patients with similar conditions for whom this treatment is not currently available?

Is this patient likely to (b) benefit significantly more than other patients with a similar condition?

OTHER INFORMATION

Q13 Patient’s BMI if (a) applicable to criteria

Lifestyle factors if (b) applicable to criteria

EVIDENCE OF EFFICACY & COST EFFECTIVENESS Evidence that the Please attach full journal articles or NICE guidance; DTC, Cancer Network etc. treatment will result in health improvement, including recent Q14 evidence of effectiveness

The completed form should be sent in confidence with any other supporting documents to:

Version: Jan 2018 v1617.1.02 Page 4 of 5 Bristol, North Somerset and South Gloucestershire CCGs

By Email to: [email protected]

Postal Address: Individual Funding Request Team Suite 15, Corum 2 Corum Business Park Warmley South Gloucestershire BS30 8FJ

In order to comply with information governance standards, emails containing identifiable patient data should only be sent securely, i.e. from an nhs.net account

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