Summary of current and Nature of Outcomes achieved. State (Start/Stop) previous interventions intervention or reasons for stopping* ‘current’ for this condition *Reasons for stopping may include: Course completed; No or poor response; Disease progression; Adverse effects; Poorly tolerated. PART 6: PROJECTED OUTCOMES What are the intended outcomes of the proposed intervention? How will the outcomes be measured? What criteria will be NB The CCG may require regular feedback on the outcome if the ‘stopping’ in place to decide when the treatment is approved. treatment is ineffective? What would you consider to be a successful outcome for the requested intervention in this patient? CLINICAL EXCEPTIONALITY PART 7: Please read before Do you consider that the clinical circumstances in your patient’s case are completing this section. exceptional? If so, why? NB The onus is on the requesting clinician to state why the clinical circumstances are exceptional. The grounds will usually arise out of exceptional clinical manifestations of the condition & greater capacity to benefit, when Do you consider there is an exceptional capacity to benefit? If so, why? compared with the general population. of patients with the condition in question at a similar stage of progression What is the anticipated need for this treatment, i.e. how often would you expect to request this treatment for this
Summary of current and previous interventions for this condition *Reasons for stopping may include: Course completed; No or poor response; Disease progression; Adverse effects; Poorly tolerated. Nature of intervention Outcomes achieved. State ‘current’ or reasons for stopping* (Start/Stop) PART 6: PROJECTED OUTCOMES What are the intended outcomes of the proposed intervention? How will the outcomes be measured? What ‘stopping’ criteria will be in place to decide when the treatment is ineffective? NB The CCG may require regular feedback on the outcome if the treatment is approved. What would you consider to be a successful outcome for the requested intervention in this patient? PART 7: CLINICAL EXCEPTIONALITY Please read before completing this section. NB The onus is on the requesting clinician to state why the clinical circumstances are exceptional. The grounds will usually arise out of exceptional clinical manifestations of the condition & greater capacity to benefit, when compared with the general population. of patients with the condition in question at a similar stage of progression Do you consider that the clinical circumstances in your patient’s case are exceptional? If so, why? Do you consider there is an exceptional capacity to benefit? If so, why? What is the anticipated need for this treatment, i.e. how often would you expect to request this treatment for this
individual-funding-request-form.docx