New Medicines Request Form
NB Please use the electronic version of this form Available at www.elmmb.nhs.uk
NB. Please complete ALL relevant sections legibly and comprehensively. Text boxes will expand to fit as information is added. Please note that any missing or illegible information will require the form to be returned to you for amendment and so may delay the application.
Please submit completed forms to:
lisa.rogan3@nhs.net  and Ana.Batista@elht.nhs.uk

Section 1: Medicine Details

Name of medicine (generic & brand name):

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Strength(s) and Form(s):

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Licensed indication(s):

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Proposed indication(s) for use (if different from or in addition to the above):

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Section 2: Evidence to Support Proposed Use

2.1 Evidence of effectiveness in the proposed indication:	
What evidence is there of effectiveness for this medicine in its intended use? Please supply information on the principal trials supporting the indication(s) described above and the overall results regarding outcomes (e.g. absolute or relative risk reduction or NNT) and efficacy?  Please state what the principal outcome measures are and provide copies of up to 3 (maximum) relevant references.

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2.2 Summary of evidence on comparative efficacy	
What are the advantages of this medicine compared to other treatments?  Consider
medicines already recommended in your local formulary or others in the same therapeutic class or used for the same indication as being requested.

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2.3 Summary of evidence on comparative safety	
How does this medicine compare to existing alternatives in terms of its safety and any associated monitoring requirements? In summarising monitoring requirements, please indicate whether they are during initial stages of treatment until the patient is stable, or are required for the full duration of therapy.

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2.4 Summary of evidence on cost effectiveness and patient outcomes	
Is this medicine more cost-effective than alternatives, or does it result in improved quality of life for patients? Please provide information on the cost effectiveness of this medicine in terms of absolute risk reduction and cost per QALY and/or quality of life benefits.

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Section 3: Place in Therapy and Impact on Alternatives

3.1 How will using this medicine change the use of other medicines or treatments?	
Please indicate whether this medicine would be used in addition to or instead of others, and where in the treatment pathway it is planned to use it, e.g. 1st/2nd /3rd line/ reserved for particular patient groups. If it will replace an existing medicine, please state which one. N.B. Please give reasons for your proposed place in therapy.

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3.2 How will using this medicine affect how services are delivered to patients?	
For example, will it require fewer or more hospital visits, enable care to be delivered closer to home, etc?

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3.3 Are there other any non-medicine costs or savings related to using this medicine?	
For example, will it require additional clinics to be set up, avoid a surgical procedure, or result in reduced length of stay in hospital?

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Section 4 Financial Implications

4.1 What is the cost per patient of the medicine each year?	
If a full course of treatment last less than one year, please indicate this and give the cost of the course.

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4.2 If this medicine replaces an alternative medicine or treatment, what is the current annual cost per patient of this alternative?	
Please include the name of the alternative medicine or treatment and the cost of one full course or one year’s therapy per patient.

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4.3 How many patients would receive this medicine each year?	
If possible, please indicate what proportion of patients with the condition to be treated would be prescribed this medicine OR indicate whether your estimate relates only to patients to be treated by your own organisation or the total across all of Lancashire.

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4.4 Where would prescribing take place? Click in the box to tick the option you propose.	
Hospital/specialist services only	☐
Initiated in hospital/specialist service and continued in primary care	☐
Initiated and continued in primary care	☐	
4.5 If prescribing in primary care is envisaged, do you think shared care guidance would be required? Please give the reason for your answer.

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Section 5: Declaration of Potential Conflicts of Interest

5.1	Personal interests over the last 12 months

This involves payments* (or other support) from any one company to an individual clinician or their spouse/partner/or close relative. The main examples are consultancies, fee-paid work, travel grants or pharmaceutical company shares. (The amount of money involved does not have to be declared).

Company	Nature or purpose of support from the company	Period of support From	To	
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Name of Clinician:  Click here to enter text.

Date:Click here to enter text.	

5.2	Organisational interests over the last 12 months

This implies support* from any one company for your unit or place of work. It may be financial or in kind, e.g. funding of a nurse, colleague, building or piece of equipment. (The amount of money involved does not have to be declared).

Company	Nature or purpose of support from the company	Period of support From	To	
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Name of Clinician: Click here to enter text.

Date: Click here to enter text.	

* for practical purposes, payments and/or support to a value in excess of £100 annually should be declared.  (Threshold of £100 chosen locally to exclude amounts for trivial items such as pens, post-its, books, etc)

Section 6: Background Information

6.1 Application Completed by:	
GP/Consultant - Name, specialty, full postal address and email address:

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Clinical Pharmacist - Name, full postal address and email address:

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6.2 Organisational support for submission given by:	
Clinical Director – Name, date:

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Chief Pharmacist – Name, date

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N.B.  Individuals  submitting  request are  responsible  for  ensuring  their  own  organisation supports the application before submitting it for consideration.