NHS Somewhere: Individual Funding Request Policy
Application for Individual Funding Requests (IFRs)
Patient Name or initials
Date of Birth
Address
NHS No
Practice name, address
and contact number
Name, address & contact
number of referring
clinician requesting
funding
Patient diagnosis /
indication
ZZ
24/03/81
XX
XXX XXX XXX
GP
Details of exceptional
circumstances for this
patient
Non union of tibial facture
Loss of income due to severely limited mobility and pain
NICE approved but not currently commissioned
Prof XXXXX
Dept of Orthopaedics
XX NHS FT
ZZ Street, ZZ City
Non Union of tibial fracture
Device / non drug treatment
Treatment /device
Exogen (Low Intensity Pulsed Ultrasound) (LIPUS)
requested
Proposed provider of
requested treatment
(where known)
Anticipated cost of device
/ full treatment
Length of treatment &
review date
Evidence of clinical
effectiveness for
indication in question or a
statement stating
compliance with NICE or
other recognised
guidance
XX Hospitals
£25 000
6 months
NICE IPG374 Low-intensity pulsed ultrasound to promote fracture
healing https://www.nice.org.uk/guidance/ipg374/resources/lowintensity-pulsed-ultrasound-for-promotion-of-fracture-healingoverview2
Busse JW, et al. (2009) Low intensity pulsed ultrasonography for
fractures: systematic review of randomised controlled trials. BMJ
338:b351 doi:10.1136/bmj.b351
Webb M. (2008) Low Intensity Ultrasound (Exogen) Therapy for
Non Union of Fractures. Public Health Wales.
AETMIS. Low intensity ultrasound (Exogen™) for the treatment of
fractures. Technology brief prepared by Reiner Banken. (AETMIS
03-05). Montréal: AETMIS, 2004,
Medicare Services Advisory Committee (2001) Low intensity
ultrasound treatment for acceleration of bone fracture healing:
Exogen bone growth stimulator. Report 52
Leung KS et al. (2004) Complex tibial fracture outcomes following
treatment with low-intensity pulsed ultrasound. Ultrasound in
Medicine & Biology 30:389–395
Schofer M, Schmelz A, Schultz M. Comparative Effectiveness Of
Low Intensity Pulsed Ultrasound Versus Sham Treatment Of Tibia
Fracture In Patients With Nonunion: A Double-Blind, Multi-Center
Randomized Controlled Trial. ISPOR 14th Annual International
Meeting 2009
Mayr E, Frankel V, and Ruter A. (2000) Ultrasound-an alternative
healing method for nonunions? Archives of Orthopaedic &
Trauma Surgery 120:1–8.
Jingushi S, Mizuno K, Matsushita T et al. (2007) Low-intensity
pulsed ultrasound treatment for postoperative delayed union or
nonunion of long bone fractures. Journal of Orthopaedic Science
12:35-41.
Rutten S, et al. (2007) Use of low-intensity pulsed ultrasound for
posttraumatic nonunions of the tibia: a review of patients treated
in the Netherlands. Journal of Trauma-Injury Infection & Critical
Care 62:902-908.
Heckman JD, Ryaby JP, McCabe J et al.(1994) Acceleration of
tibial fracture-healing by non-invasive, low-intensity pulsed
ultrasound. Journal of Bone & Joint Surgery -American 76:26–34.
Leung KS, Lee WS, Tsui HF et al. (2004) Complex tibial fracture
outcomes following treatment with low-intensity pulsed
ultrasound. Ultrasound in Medicine & Biology 30:389–395
Gebauer D, Mayr E, Orthner E et al. (2005) Low-intensity pulsed
ultrasound: effects on nonunions. Ultrasound in Medicine &
Biology 31:1391-1402.
Drug treatment only
Intervention requested
Anticipated cost of full
course of treatment
Planned duration of
treatment & review date
How will the
effectivesness be
monitored?
Is the treatment licensed
for this indication?
Has this treatment been
approved / rejected by
NICE?
Evidence of clinical
effectiveness for
indication in question
Clinical reasons for the
request and relevant
detailed medical history,
including all treatments
tried to date (include
privately funded
treatment)
Explanation of why 1st line
or alternative treatments
are not suitable if
applicable
Summary of the clinical
benefits the referrer
believes the treatment will
have for the specific
patient:
N/A
Yes
Yes- approved
As above
Fracture following traumatic injury- skiing
Closed reduction and mobilisation (overseas) and return to UK
Failed to unite
Unable to weight-bear – severely limited mobility
See above
Improve fracture healing, reduced need for further operative
interventions, and reduced time to return to function.
Decreased costs to NHS and to patient
Name & address of any
other clinicians involved
in current patient
management:
Is the patient aware of the
request for funding?
Are you happy for us to
obtain consent and
contact the patient
regarding this request for
funding?
Any other relevant
information:
Please provide
declaration of interests
GP
Yes
Yes
I declare no conflicting interests in this case
Signed:…………………………………………………(requesting Clinician)
Name:………….………………………………………..
Date:……………………………………………………..