Product Request

A. Product Information

Trade name / generic name


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

Launch Date

Licensed Indications



B. Commissioning issue for consideration

For example;

  • 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


Professional Role

Telephone Number

Postal Address


Your E-mail Address