Non-Formulary Drug (NFD) Request Form for Named Patient Use

Patient details:

Patient name & DOB:	Ward/Clinic:
Hospital number:	Weight (kg) if applicable:

Non-formulary medicine details:

Approved name:

Dose:	Formulation & Route:	Frequency:	Duration of treatment:
Does this medicine have a UK product licence?: Yes □ No □ (If No, please also complete unlicensed medicine form)
Indication for use in this patient:
Is this a licensed indication: Yes □ No □ (If No, please also complete off-label medicine form)

Reasons for request:

CATEGORY 1 - CONTINUATION OF THERAPY (Dispensary Manager/Ward Pharmacist to complete)	(
Patient’s own supply checked and either unsuitable for use or has been used up:
Supply unavailable at home or unable to bring in: (NB: GPs must not be asked to prescribe for use in hospital)
Formulary option suggested and discussed with medical team, but inappropriate to switch to formulary choice
CATEGORY 2 - INITIATION OF THERAPY (Requesting Consultant to complete)	Please provide brief details below
Previous therapy used to treat condition to date (include doses and duration if possible):

Previous therapy ineffective:
Adverse reaction to previous therapy:
No formulary option available:
Recommendation from specialist centre:
Other (please state):

Requesting consultant or pharmacist

Consultant:	Consultants Signature:
Ordering Pharmacist:	Dispensary Manager Signature:
Date:	Phone/Bleep:

Instructions:

Category	Definition	Action
1 – Continuation	Required for patient admitted on existing therapy that is not appropriate to change to a formulary alternative.	Ward Pharmacist – Order on supply sheet and Dispensary Manager will complete a form and send to procurement.
2 – Initiation	Required for a single patient, in an unforeseen, urgent or an emergency situation; often on advice from a specialist centre.	Consultant – Complete all sections of this form and send to the Principal Pharmacist of the relevant directorate. Once approved, medicine will be ordered.

GUIDANCE FOR STAFF:

Purpose of Non-Formulary Drug (NFD) Request Form

The NFD request form presents a means whereby patients for whom formulary options may not be clinically appropriate may access treatment. The formulary is expected to cover the majority of prescribing and it is estimated that it will provide clinically appropriate options for treating over 80% of patients’ medication needs.

The NFD request form allows trends in prescribing outside of the formulary to be monitored and reported. This allows the formulary to be updated when necessary.

NFDs are not routinely stocked in the pharmacy department; there may be a significant delay in obtaining the product and therefore where appropriate the patients’ own drugs should be used to avoid a delay or keep to a minimum any disruption in treatment whilst obtaining the NFD.

What pharmacy staff must do when asked to obtain a NFD

An admission to hospital represents an opportunity to review a patient's existing drug therapy and, if appropriate, treatment may be changed to a drug that is on the MK Joint formulary.

If a patient is admitted on a NFD, and there is no clinically appropriate alternative available on the formulary or if it is considered clinically unreasonable to change to a drug included in the formulary, the ward pharmacist should request the item on a supply sheet; Dispensary Manager will complete a form and give to procurement for ordering.

If a patient is to be initiated on a NFD in an unforeseen, urgent or an emergency situation; often on advice from a specialist centre, the Consultant should complete all sections of this form and send to the Principal Pharmacist of the relevant CSU for approval then passed to the Dispensary Manager.

How the use of NFD will be monitored

These NFD request forms will be audited bi-monthly by the Pharmacist Manager Medicines Information & Formulary and trends in use reported to the Milton Keynes Prescribing Advisory Group (MKPAG) and in turn to the relevant CSUs in order to highlight any necessary formulary submissions.

What are our contractual obligations in relation to requesting GPs to prescribe NFD?

All prescribing from within the Trust (i.e. in-patient, out-patient and FP10 prescribing) should comply with the formulary. The pharmacy department will monitor this and take appropriate action.

Advice given to GPs with regard to drug treatment options must also be in line with Trust formulary recommendations. However, it is acceptable to request a GP to prescribe a NFD, if there is a clinical need and there is no other suitable formulary alternative.

When advising the GP, the consultant should:

Acknowledge the formulary status of the medicine, rationale for that particular medicine, any licensing issues and any cost impact.

Ensure that the GP has the information necessary to continue the use of the medicine if they are expected to assume the clinical responsibility for prescribing the NFD to the patient.

When a NFD has been initiated during an in-patient episode, the discharge letter should contain the above information in 3.3.1 and 3.3.2.

When a NFD is necessary following an outpatient consultation, the Outpatient Prescription Advice letter must contain the above information in 3.3.1 and 3.3.2.

When a NFD is initiated following an outpatient consultation on an FP10, the above information in 3.3.1 and 3.3.2 should be clearly communicated to the GP in writing. The patient should not be used as a method of communication.

Pharmacy Use Only:

Initiation Approval:

Date received: ______________ Approved (Name/Signature): __________________________________ Date: ______________

Procurement:

Ordered by (Name/Signature): ___________________________	Date: _______________ Cost (incl. VAT): _______________

Stores:

Booked in by: ____________________________	Date: ___________________

Dispensary:

Dispensed by:___________________	Date: ______________	Checked by: ___________________	Date: _____________

Non-Formulary Medicine Request Form for Named Patient Use

kufeji folake

2015-05-27

Beason Nicholas (RD8) Milton Keynes Hospital

Milton Keynes General NHS Trust