Non-routine Medicine Funding Request (NMFR) Form Effective September 2017

Transcription

1 Non-routine Medicine Funding Request (NMFR) Form Effective September 2017 This form should be completed by a patient or patient representative in circumstances where a patient wishes to receive a medicine that has been classified by Surrey Heath CCG as black status, i.e. not recommended for use in any health setting across Surrey. Note: Black status is applied for one or more of the following reasons: 1. Lack of evidence of benefit compared with standard therapy 2. Lack of evidence of safety compared with standard therapy 3. Less cost-effective than standard therapy 4. NICE guidance does not recommend Please read the guidance notes on the back page before completing this form. Incomplete application forms received will be returned to the requestor. The application will be considered by the Surrey Heath CCG NMFR Panel within 21 days and the requestor and their GP will be notified of the decision within 5 working days Please send the completed form to: Quality Team NHS Surrey Heath CCG Surrey Heath House Knoll Road CAMBERLEY, Surrey, GU15 3HD Or to: SHCCG.QualityIssues@nhs.net Acknowledgement of receipt of the application will be provided within 5 working days PART 1: DETAILS OF PERSON SUBMITTING REQUEST AND PATIENT Name 1. Details of person submitting the request Title: Correspondence address: (including Postcode): Telephone Number: Relationship to patient Date completed Surname: 2. Patient details First name: Title:

2 Address (including Postcode): NHS Number (if known) Date of Birth: Registered GP name: Registered GP practice: Gender 3. Instructions for communicating with the patient Does the patient wish to receive letters regarding this request? Yes No If YES are the letters to be sent to the patient at the address above? Yes No If letters are to be sent to anyone other than the patient, please provide the following information, and obtain the patient s written agreement: Name Relationship to patient Address (including Postcode) PART 2: CONSENT I have informed my GP that I am making this application. I declare that I provide consent for the personal confidential and sensitive information on this form to be passed to the CCG for processing this request for funding with the Non-routine Medicines Request Panel. This includes staff contracted by the CCG to support this process. I hereby give my consent for the organisations listed below to share any relevant information in order to complete my application. I understand that this is likely to include disclosure of the patient s personal/clinical records. 4. Declaration Surrey Heath CCG My GP Practice I understand that information exchanged as agreed by me must be used solely for the purpose for which it was obtained. I further understand that my consent will expire at the conclusion of the application. Signature Name: (BLOCK CAPITALS) Page 2 of 10

3 Date: I am the Patient Patient s representative (delete as appropriate) If you are the patient s representative, please tick the box below to confirm that you have the patient s permission to make this application Page 3 of 10

4 PART 3: EQUALITY AND DIVERSITY MONITORING FORM PATIENT DETAILS Gender Male Female Do you now, or have you ever considered yourself Transgender? Yes No information I would describe my ethnic origin as Asian or Asian British Bangladeshi Indian Pakistani Any other Asian background Black or Black British African Caribbean Sudanese Any other Black background. Mixed Asian & White Asian & Black African Asian and Black Caribbean White & Black African White and Black Caribbean Any other mixed background White British Irish Gypsy /Traveller Polish Portuguese Any other White background... Other Ethnic Group Chinese Turkish Arab Japanese Any other ethnic group (please give details) Please select the option which best describes your sexual orientation Lesbian Gay Bisexual Heterosexual Other (please state).. Page 4 of 10

5 Please indicate your religion or belief Agnostic Atheism Buddhism Christianity Hinduism Islam Jainism Judaism Pagan Sikhism Other... I have no particular faith Do you consider yourself to have a disability or long term limiting condition? Yes No Please state the type of impairment which applies to you. People may experience more than one type of impairment, in which case you may indicate more than one. If none of the categories apply, please mark other. Physical Impairment Sensory Impairment Mental Health Condition Learning Disability/Difficulty Long-term illness Other (please state). Are you a carer? Yes No If yes do you care for.? Parent Child Other family member Partner / spouse Friend Other.. What age are you? Date received: Identifier: Identifier assignment checked by: Please note pages 1 to 3 containing confidential details of patient s name, etc. will be removed before the remainder of the form is copied and seen by NMFR Panel members. Page 5 of 10

6 PART 4: DETAILS OF THE REQUEST Name (brand): 5. Requested medicine Strength: Dosage form (tablet, capsule, liquid etc): Dose: 6. Briefly describe the condition you wish to use the medicine for 7. Please provide information on any other medicines that you have previously been prescribed to treat this condition and the reasons why these were stopped Your GP 8. Who originally initiated the requested medicine? NHS hospital doctor Private doctor 9. If you have previously been prescribed the branded product, when was treatment started? 10. How long have you tried a generic version of this medicine? Page 6 of 10

7 11. Have you tried more than one generic version of the medicine (if yes, please state the number of versions)? 12. Explain why available generic versions of the requested medicine are not appropriate in this case 13. Provide information about any individual clinical circumstances that you feel would support this application Thank you for completing this form Page 7 of 10

8 GUIDANCE NOTES FOR COMPLETING THIS NMFR FORM Introduction Surrey Heath Clinical Commissioning Group (CCG) is responsible for planning the right services to meet the needs of local people, buying local health services including community health care and hospital services, and checking that the services are delivering the best possible care and treatment for those who need them. It is important for the CCG to make sure that treatment and drugs are only used where there is strong evidence of real clinical benefits to patients. Resources are limited, and they have to be managed to get the best health results for as many people as possible in your area. The CCG have systems in place to decide which treatments and drugs will be used locally and which will not. What medicines are not normally funded by your CCG? Medicines will not normally be provided if: There is little scientific proof that they will work There is a lack of evidence of benefit compared with standard treatments There is a lack of evidence of safety compared with standard treatments They are less cost effective than other treatments i.e. there are other options available that are just as effective, but do not cost as much They are treatments which are subject to clear criteria which have not been met. National Institute for Health and Care Excellence (NICE) guidance does not recommend When can a non-routine medicines funding request be made? A non-routine medicines funding request can be made for a medicine not routinely offered by the CCG when a patient is clearly different to other patients with the same condition or where the patient might benefit from the treatment in a different way to other patients. This is known as clinical exceptionality. You can make a non-routine medicines funding request (NMFR) if you believe that a particular medicine that is not routinely offered by the CCG is the best treatment for you, given your individual clinical circumstances, when it might mean that other patients in a similar situation do not receive the same medicine. Why all these questions? Please be assured there is good reason for all the questions on this form. Not every question need be answered for every case; but please signify not applicable rather than leaving a blank. Part 1: Details of patient and clinician submitting the request We need to contact you so full details every time please. We must be able to identify the patient. If you are completing the application on behalf of a patient, please ask your patient to choose whether s/he wishes to receive correspondence about the progress of his/her IFR: if YES please indicate where letters should be directed. Part 2: Consent Your signature at this point validates the whole request. An unsigned form cannot be accepted. Please note that you must inform your GP that are submitting the request so that they are aware of the process. Part 3: Equality and diversity monitoring form This information is optional and the Panel will not view this information. This information will be used to enable audit to take place to identify if particular sections of the community are being disadvantaged through the NMFR process. Part 4: Details of the request The fullest possible information will help the Panel make a decision. Q5 - Requested medicine please provide the name of the branded medicine that you are requesting, for example, if you were requesting Losec 20mg capsules then: Name (Brand) = Losec Page 8 of 10

9 Strength = 20mg Dosage form - capsules Q6 -Briefly describe the condition you wish to use the medicine for Intervention for which funding is requested. Tell us why your doctor has prescribed this medicine for you, e.g. for diabetes, Q7. Please provide information on any other medicines that you have previously been prescribed to treat this condition and the reasons why these were stopped. Reasons for stopping may include: - course completed - no or poor response - disease progression - adverse effects / poorly tolerated Q10. How long have you tried a generic version of this medicine? Please provide information on how long you have previously tried a generic version of this medicine. Please also state if you have tried more than one generic version of the medicines Q11. Have you tried more than one generic version of the medicine (if yes, please state the number of versions)? There are usually a number of generic manufacturers of generic medicines. If you find that a particular version doesn t agree with you it is possible that other versions may suit you better. Community pharmacies are usually happy to seek alternative generic versions at patient s request Q12. Explain why available generic versions of the requested medicine are not appropriate in this case Please provide as much information as possible, including the type of side-effects you may have experienced and whether you reported these to your GP 13. Provide information about any individual clinical circumstances that you feel would support this application This section is vital for you to describe the key reasons for your request. Your request will only be approved if you can demonstrate clinical exceptionality or rarity. Clinical exceptionality can be difficult to define but you will need to be able to demonstrate what makes your clinical presentation different to other patients in the same or similar situation. The word clinical in this context relates to your medical condition and treatment. The Court of Appeal 1 has confirmed that Exceptionality is essentially an equity issue that is best expressed by the question: On what grounds can the NHS commissioner justify funding this patient when others from the same patient group are not being funded? When considering rarity, the NMFR Panel will use NHS England s definition which is 1 case in 2.5 million. What information will not be taken into account? Generally, the CCG does not take into account non-clinical factors in deciding what treatment to provide. The CCG recognises that everyone s life is highly individual and unique and that non-clinical factors may seem to be of vital importance to patients when asking for treatment. However, consideration of non-clinical and social factors would be contrary to the CCG policy of non-discrimination in the provision of medical treatment. Such non-clinical factors would include having children/not having children, being in employment/not being in employment, being a carer/not being a carer and so on. In reaching a decision as to whether a patient s circumstances are exceptional, the CCG is required to follow the principle that non-clinical or social factors are not relevant, as it would be impossible to know whether the CCG is being fair to other patients who are denied such treatment and whose social factors are entirely unknown. Page 9 of 10

10 For help in filling this form out please your query to the Quality Team at who will be able to help you. Page 10 of 10