Procedure that requires Prior Approval

Application form: Inguinal Hernia

Name of GP/ Consultant requesting funding

Practice Name/ Trust of applicant

Contact telephone number

Contact NHS.Net email address

Patients NHS Number

Consultants name (if known)

For onward referral
Hospital/ NHS Trust name (if known)
For onward referral
This form is to be completed by the GP/Consultant when applying for funding for individual patients for clinical
procedures which require Prior Approval or Procedures Not Routinely Funded.
Email the completed document and papers to the IFR service at: Beds.IFRrequests@nhs.net
PLEASE NOTE: Asymptomatic or minimally symptomatic Inguinal Hernias: these will not normally be funded. A
period of watchful waiting approach is advocated. Patients should be advised to seek further medical advice if
symptoms or signs change.

Patient Consent By submitting this request you are confirming that you have fully explained to the patient the proposed treatment and they
have consented to you raising this request on their behalf.

Is the patient aware of this referral and the contents of this form and supporting documents? YES NO

I confirm that the patient consents to the CCG IFR Team accessing personal clinical information about them that is YES NO
held by IFR staff to enable full consideration of this funding request?
Please complete the following sections in full. Incomplete applications will not be considered and will
be returned.

Clinical Criteria required for consideration for treatment Please tick and add details and dates
where requested
1. Does the patient suffer with ongoing pain which significantly
YES NO
interferes with activities of daily living.

Please provide details

2. The patient suffers at least one of the following work-related issues:

YES NO
a) unable to carry out light duties because of the hernia OR
b) time off work/missed work/unable to work because of the hernia.

Please provide details

3. Is there a history of incarceration of, or real difficulty/impossible in

YES NO
reducing the hernia (unable to reduce after repeated efforts)?

Please provide details

South, Central and West Commissioning Support Unit October 2015 PLEASE TURN OVER
 4. Is it an inguino-scrotal hernia?
YES NO

5. There has been a documented increase in size of the hernia month to

YES NO
month and the hernia is of a large size.

Please provide details

6. What are the significant symptoms and how long has the patient noticed the hernia?

i.e. intermittent or prolonged pain

Please provide details

7. Is the patient asymptomatic but work is a heavy manual occupation

YES NO
(e.g. in removal firms lifting heavy weights) and there is a risk of
strangulation?

Please provide details

8. Please provide the patients current

BMI
Patient’ Body Mass Index (BMI)
Height Height
Weight
Weight
9. Is the patient a non-smoker?
YES NO

10. Exceptional circumstances may be considered where the patient’s capacity to benefit from that treatment is likely
to be different to that of other patients with the same condition because they are reasonably expected to obtain a
significantly better clinical outcome from that treatment than would be expected from other similar patients.

Please provide details

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.
Please email the completed form to Beds.IFRrequests@nhs.net for consideration.

South, Central and West Commissioning Support Unit October 2015