School of Pharmacy

MTRAC PRODUCT REQUEST FORM

If you wish to complete and return this form attached to an email, please download the form here and email to mtrac@keele.ac.uk.

Product name:

A. Product Information

Trade name / generic name:

Manufacturer:

Current marketing status (e.g. launched in UK, EMA approved, in clinical trials):

Launch Date:

Licensed Indications:

Dose:

Cost:

B. Commissioning issue for consideration e.g.

• Identification of patient cohort most likely to benefit
• Cost impact versus benefit gained
• Service implications e.g. impact on care pathway (lab tests, other healthcare service activity etc.), secondary care attendance, capacity in primary care
• QIPP - opportunity?
• CCG budget/resource management
• Other NHS requirements e.g. Local Healthwatch, NHS Operational Framework

C. Does the SPC assign responsibility for the prescribing of this product?

D. National or other Guidance in existence?

• Is the product on the NICE programme and if so when is the guidance expected?
• Is national guidance ambiguous e.g. "can be considered as an option"?
• Would more specific guidance be of value when only general guidance is available e.g. in a NICE Clinical Guideline?

E. Proposer

Name:

Professional Role:

Telephone number:

Postal address:

Date:

Your Email address: