<p> Procedure that requires Prior Approval Application Form: Non Specific Back Pain (Including Spinal Discectomy, Spinal Fusion, Trigger Point & Sclerosant Injections) There is a separate proforma for Facet Joint injections, Medial Branch Blocks and Epidural Injections Name of GP/ Consultant requesting funding</p><p>Practice Name/ Trust of applicant</p><p>Contact telephone number</p><p>Contact NHS.Net email address</p><p>Patients NHS Number Consultants name (if known) For onward referral Hospital/ NHS Trust name (if known) For onward referral In the first instance GP’s should refer to the Bedfordshire MSK service for assessment and treatment. Prior approval is required for this treatment prior to referral or treatment in secondary care. All patients should have access to high quality conservative management before surgery is considered. This form is to be completed by the GP/Consultant when applying for funding for individual patients for clinical procedures which require Prior Approval or Procedures Not Routinely Funded. Email the completed document and papers to the IFR service at: [email protected] Please note that unless 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. </p><p>Patient Consent: By submitting this request you are confirming that you have fully explained to the patient the proposed treatment and they have consented to you raising this request on their behalf. </p><p>Is the patient aware of this referral and the contents of this form and supporting documents? YES NO</p><p>I confirm that the patient consents to the CCG IFR Team accessing personal clinical information about them that is held YES NO by IFR staff to enable full consideration of this funding request?</p><p>Please Complete this form in full</p><p>1. Part 1: Which type of treatment are you requesting? (E.g. Spinal Fusion, Spinal Discectomy, Trigger Point Injection etc.)</p><p> a) Diagnostic? b) Therapeutic? YES NO YES NO </p><p>FOR ALL PATIENTS – PLEASE PROVIDE THE FOLLOWING: Please complete ALL sections in full</p><p>2. Details of historical pain: Please note the Panel will only consider your request if the patient has had documented pain in the long-term, i.e. one year or over. Does the patient have a confirmed diagnosis/cause for this pain? Please give full details:</p><p>South, Central and West Commissioning Support Unit October 2015 PLEASE TURN OVER a) Type of Pain</p><p> b) Duration of Pain (NB: Pain scores must be via McGill Pain Questionnaire, or VAS) c) Recent Average Pain Score(s) over the latest 3 months with all dates:</p><p> d) Which non-drug treatments & measures have been tried, (please include all conservative measures)?</p><p>3. Please confirm the locations of Pain that the patient has? E.g. Thigh, foot, central etc.</p><p>Does the patient have pain significantly affecting activities of daily living? YES NO Full details must be given:</p><p>Has the patient been through a comprehensive pain management programme? YES NO Please give full details:</p><p> e) Has this patient received any pain treatment privately? YES NO f) If YES, please indicate which treatments have been treated privately?</p><p>What drugs have been tried for this condition? Date Date Drug Dose Started Stopped Outcome & Reason for Stopping/ Continuing – (e.g. state the side effect if it did not work, or reason for continuing) (approx) (approx)</p><p>South, Central and West Commissioning Support Unit October 20152 PLEASE TURN OVER Part 2: For patients who have already received previous treatment or surgery for this </p><p>YES (please NO (go to Please confirm whether this patient has received treatment previously? provide details) PART 3)</p><p>Please provide specific details of all interventions/treatments</p><p>Type and Number of previous interventions/treatments? Also, please indicate over what period of time?</p><p>Anatomical site of previous interventions/treatments : Details of the extent of the health benefit received from previous interventions/treatments, and detail the duration of relief this provided:</p><p>Has the patient been involved in active rehabilitation programmes YES NO If yes, please provide details</p><p>Please provide the patients Body Mass Index (BMI) Body Mass Index (BMI) Height Height Weight Weight Is the patient a non-smoker? YES NO </p><p>Why do you think this patient should be an exception to current policy or considered to have an exceptional health need for the intervention requested? (please see footnote for definition)</p><p>If funding is not approved what is the possible alternative treatment? </p><p>SIGNATURE OF CLINICIAN ……………………………………………………………. DATE: …………………………………………………..</p><p>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:</p><p>South, Central and West Commissioning Support Unit October 2015  Significantly different to the general population of patients with the condition in question and  likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. However:  The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception.  If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional.  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. Please email the completed form to [email protected] for consideration.</p><p>South, Central and West Commissioning Support Unit October 20154 PLEASE TURN OVER</p>