Funding Requests – South, Central and West



Excluded: Procedure not routinely fundedApplication form: - Facet joint injections and medial branch blocks for chronic neck painName of Referring Clinician GP Name and SurgeryPatient NHS NumberIs the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf?Yes ?No ?Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request?Yes ?No ?Is this a patient/guardian led application?Yes ?No ?Most Urgent: Decision needed within a week as the patient’s life may be in danger.?Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate.?Routine: Decision needed in 4 to 6 weeks.?Thames Valley Priorities Committee has considered the evidence for the clinical and cost effectiveness of therapeutic and diagnostic facet joint injections and medial branch blocks for the treatment of chronic low back and neck pain. The Committee concluded that the evidence for clinical and cost effectiveness is inadequate and therefore recommends that facet joint injections and medial branch blocks for diagnostic and therapeutic purposes are not normally funded. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: BerksEast.IFRrequests@ for consideration.The policy statements are available at .Please complete the following sections in full. Incomplete applications will not be considered and will be returned.Clinical Criteria required for consideration of treatmentPlease TickWhat type of injection is requested??Facet Joint Injection for chronic neck pain – for diagnostic purposes.?Facet Joint Injection for chronic neck pain - for therapeutic purposes?Medial Branch Block for chronic neck pain – for diagnostic purposes.?Medical Branch Block for chronic neck pain - for therapeutic purposesNB: Please use alternative form for Injections for the management of low back pain and sciatica.Has the patient followed the recommended pathway including the local MSK where available?Please attach the MSK referral information to the case file.YES?NO? 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.How long has the patient been managing with the symptoms?Cause of Pain:Type of Pain:Duration of Pain:Recent Average Pain Score(s) over the latest month with dates:DateAverage Pain ScoreConservative MeasuresPlease detail which non-drug treatments and conservative measures have been tried?Completed weight loss program (where applicable)?Exercise?Physiotherapy?Self-managementPlease provide specific details:Are the patient’s symptoms persistent and do they significantly interfere with activities of daily living?Please indicate:?Work-related issues – Light duties because of the condition?Work-related issues – Off work/missed work/ unable to work due to condition?Domestic activities?Carer activitiesYES?NO?What drugs have been tried for this condition?DrugDoseDate Started (approx.)Date Stopped (approx.)Outcome & Reason for Stopping /Continuing (e.g. state the side effect, if it did not work or reason for continuing)For patients who have already received previous injections:Date of the most recent injection:Number of previous injections:Anatomical site of previous injection:Details of the extent of the health benefit received from the injection and over what period of time:Patient’s Body Mass Index:BMIkg/m2HeightcmWeightkgIs the patient a non-smoker?YES?NO?Exceptional health need of this patient. Please provide details of the exceptional health need of the patient?If funding is not approved what is the possible alternative treatment?SIGNATURE OF CLINICIAN …………………………………………………………….DATE: …………………………………………………..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:? 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. ................
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