INDIVIDUAL TREATMENT REQUEST
Please type and ensure that you complete all relevant details.
1. PATIENT DETAILS
Patient Last name:
First name(s):
Date of Birth :
NHS number:
Address:
Post Code:
GP Name:
Practice Address:
Post Code:
2. DETAILS OF APPLICANT
Last name:
First name(s):
Designation:
Telephone Number:
Trust or GP Practice Name:
Secure E-mail: We will use this email for correspondence. If you are out of county – please provide an
nhs.net account (if this is not possible we will need to use an encryption facility)
Postal address for correspondence, including post code, (if different from above)
Provider Trust approval (please indicate as appropriate):
Drugs and Therapeutics Committee (DTC) or equivalent
YES
NO
N/A
Multidisciplinary Team (MDT)
YES
NO
N/A
If discussed and supported by an appropriate DTC / MDT, please provide notes here:
Please provide further information here on any discussions or advice why not applicable:
3. PATIENT CONSENT
Patient Consent:
I confirm that this Individual Treatment Request (ITR) has been discussed in full with
the patient.
The patient is aware that they are consenting for the Individual Treatment Team
and, if necessary, the Individual Cases Panel to access confidential clinical
information held by clinical staff involved with their care, about them as a patient, to
enable full consideration of this treatment request.
Has the patient been placed on the waiting list?
If relevant, has a TCI date been issued?
Yes / No
Yes / No / NA
Yes / No
Please inform your patient that the Individual Patient Treatment Team will only
correspond with the requesting clinician and the patients’ GP unless a case is
presented at Panel.
In this instance the Panel response letter will be copied to the patient unless the
patient or clinician has indicated otherwise.
Please indicate as follows:
I confirm that it is appropriate for the patient to be copied into Panel
correspondence.
Yes / No
Signature of Applicant:
Date:
Do you have any conflicts of interest relating to the requested treatment?
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Yes / No
Please note that the onus lies with the requesting clinician to present a full submission which
sets out a comprehensive and balanced clinical picture of the history and present state of the
patients’ medical condition, the nature of the treatment requested and the anticipated benefits
of the treatment. All supporting information including research papers must be submitted with
this form.
Requests can only be considered based upon the information provided. Incomplete forms
providing insufficient information will be returned.
4. TREATMENT REQUESTED
5. DIAGNOSIS
6. INCIDENCE AND PREVALENCE
Please provide an estimate of the incidence and/or prevalence of this condition: how often would you
expect to request this treatment for this condition at this stage of progression of the condition for a given
size of population.
Incidence: ........................................
(For example, the number of patients expected to develop this condition per million population per year):
Prevalence:.........................................
(For example, the number of patients expected to have this condition per million population at any given
time):
Please provide references for the stated incidence and prevalence here and attach full text articles with the
request form if they are available.
How often would you expect to request this treatment for this condition at this stage of progression of the
condition?
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7. EXCEPTIONALITY
To meet the definition of ‘exceptional clinical circumstances’ your patient must demonstrate that they are
both:
 Significantly different clinically to the group of patients with the condition in question and at the
same stage of progression of the condition or the condition is extremely rare;
AND

Likely to gain significantly more clinical benefit than others in the group of patient with the
condition in question and at the same state of progression of the condition
Do you consider this patient to have any exceptional clinical circumstances? For further guidance
on how the NHS Dorset CCG defines an exceptional case please consult the relevant sections within
its Policy for Individual Patient Treatment, these are:


Section 5
Appendix C
If so please give your reasons:
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8. SERVICE DEVELOPMENT
Is this a service development ?
Yes / No
If so has it been discussed with the relevant NHS Dorset Clinical Commissioning
Programme?
Yes / No / NA
Do you plan to submit a future business case for funding of this treatment
(rather than submit individual requests for single patients)
Yes / No
If this treatment were to be funded for this patient on an individual basis,
would the decision set a precedent for other requests
Yes / No
If you have answered yes to any of the above questions please provide further detail
9. EVIDENCE OF CLINCIAL AND COST EFFECTIVENESS/SAFETY
If drug therapy is requested, is this request outside of licence
for the intended use?
Yes / No / NA
Is this request outside of NICE TA guidance?
Yes / No / No NICE TA guidance
If so, is there other guidance in respect of this treatment for
this indication e.g. other NICE guidance or guidance from SIGN
or other national, European or international bodies?
Yes / No / NA
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What is the evidence base for the clinical and cost effectiveness/safety of this procedure treatment? Please
include all relevant clinical research and/or peer reviewed systematic review of evidence.
Is the procedure/treatment part of a current or planned national or international clinical trial or audit?
YES/NO
10. CLINICAL BACKGROUND
What is the patients’ clinical severity and current performance status, what test (where possible use
standard scoring systems e.g. WHO, DAS scores, walk test, cardiac index etc)
What previous therapies have been tried and what was the response? Please provide details in respect of
tolerance, complications, and adverse effects. Please also advise whether the patient was compliant with
treatment.
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What is the current treatment provided and what has been the response? Please provide details in respect
of tolerance, complications, and adverse effects. Please also advise whether the patient was compliant with
treatment.
What are the anticipated clinical benefits in this individual case of the particular treatment requested over
other available options?
Why are the standard treatments (those available to other patients with this condition/stage of the disease)
not appropriate for this patient? What would be the anticipated prognosis if the treatment requested was
not provided?
How will the benefits of the procedure/treatment be measured?
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What are the intended outcomes and how will these be determined?
What ‘stopping’ criteria will be in place to decide when the treatment is ineffective?
How frequently has your unit undertaken this treatment/procedure and what were your results?
Is this treatment/procedure subject to Trust audit?
Please include any available data on the use of this treatment/procedure by your Trust.
11. AFFORDABILITY
What is the cost of the treatment/procedure and how does this compare with the cost of the standard
therapy it would replace?
Please note this section must be completed to avoid delays in decision making
How will the treatment/procedure be given to the patient (e.g. oral/IV etc) and where will the treatment
take place?
Is this a single treatment/procedure or part of a course?

If part of a treatment course, what is the number of doses that will be given and at what intervals

What is the total length of time of the proposed course of treatment
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12. OTHER
Clinicians are required to disclose all material facts to NHS Dorset CCG as part of this process.
Are there any other comments/considerations that are appropriate to bring to the attention of the
Individual Patient Treatment Team?
13. GP INVOLVEMENT
Where the applying clinician is not the patients’ GP; is the GP aware of this
request and has the GP had an opportunity for input?
Does the GP support this request?
Yes / No
Yes / No / Do not know
Return completed form to:
Address:
NHS Dorset Clinical Commissioning Group
Individual Patient Treatment Team
First Floor West
Vespasian House
Bridport Road
Dorchester
DT1 1TS
Email:
Individual.requests@dorsetccg.nhs.uk
or
DOCCG.IndividualRequest@nhs.net
Telephone:
01305 368936
Safe Haven Fax:
01305 368947
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