Herefordshire CCG Treatments Policy

Transcription

1 Herefordshire CCG Treatments Policy This Policy should be read in conjunction with the CCGs guidance on Optimise Your Health before Surgery, which seeks to provide support and guidance to patients so that they get the most benefit from any treatment or procedure `

2 Subject and version number of document Policy number Category Author The Herefordshire Treatments Policy HCCG0059 Clinical Treatment Policy Review Group CCG policy owner Impact assessments required Impact assessments completed Director Of Operations Equality Impact Assessment Quality Impact Assessment Privacy Impact Assessment Equality Impact Assessment Quality Impact Assessment Privacy Impact Assessment Links to other policies The Treatment Policy is in conjunction with the Optimise your Health Guidance Guidance Last revised February 2018 Review date March 2019 Operative date October 2017 March 2019 For action by Director of Operations Herefordshire Providers Herefordshire Primary Care teams Policy statement Contained in page 7 Responsibility for dissemination to new staff Mechanisms for sharing Line managers HCCG website, GP Parliament, Notification to Providers Training implications Resource implications Further details and additional copies available from Website: Master copy saved CCG Live Policies Folder `

3 Document Sign Off Approval / Ratification Date Reported to Date Clinical Executive 13 February 2018 `

4 Contents 1 INTRODUCTION BACKGROUND POLICY STATEMENT GOVERNANCE AND AUTHORISATIONS LIFESTYLE FACTORS AND SURGERY PSYCHOLOGICAL FACTORS AND SURGERY SCOPE IMPLEMENTATION MONITORING AND REVIEW COPIES OF THIS POLICY GLOSSARY OF TERMS APPENDIX 1 - TREATMENT PROCEDURES SECTION A.2 EQUIPMENT SECTION A.3 EAR, NOSE AND THROAT SECTION A.4 GENERAL SURGERY SECTION A.5 MENTAL HEALTH SECTION A.6 MUSCULO-SKELETAL SECTION A.7 NEUROLOGY/NEUROSURGERY SECTION A.8 OBSTETRICS AND GYNAECOLOGY SECTION A.9 OPHTHALMOLOGY SECTION A.10 ORAL SURGERY SECTION A.11 OTHER PROCEDURES AND TREATMENTS SECTION A.12 PAIN SECTION A.13 UROLOGY APPENDIX 2 - HEREFORDSHIRE MEDICINES OPTIMISATION (September 2017 Version 1.2) APPENDIX 3 PRIOR APPROVAL and INDIVIDUAL FUNDING REQUEST PROCEDURE APPENDIX 4 PRIOR APPROVAL APPICATION FORM APPENDIX 5 VERSION HISTORY `

5 Equality analysis initial assessment Title of the change proposal or policy: Herefordshire CCG Treatments Policy Brief description of the proposal: Refresh of existing Low Priority Treatment Policy in order for closer alignment with regional policies. The original policy has gone through full QIAs and EIAs and it not proposed that these are required for the refresh. Name(s) and role(s) of staff completing this assessment: Hazel Braund Director of Operations Herefordshire CCG February 2018 Please answer the following questions in relation to the proposed change: Will it affect employees, patients, and/or the public? Please state which. The will be no significant impact on employees, customers and the public. Is it a major change affecting how a service or policy is delivered or accessed? There are no changes being proposed which are considered to be significant in their impact. The changes made to the Prior Approval and Individual Funding Requests process provide greater clarity on how treatments within the policy can be accessed where appropriate. Will it have an effect on how other organisations operate in terms of equality? No If you conclude that there will not be a detrimental impact on any equality group, caused by the proposed change, please state how you have reached that conclusion: The policy has been updated following a significant process of engagement with both primary and secondary care clinicians and Herefordshire Council s Public Health service. Throughout this engagement there has been close consideration of any detrimental impact on patients and patient groups in regard to quality and equality. In future where proposals are made which are considered to have a detrimental impact they will go through a full EIA and QIA. `

6 1 INTRODUCTION The Herefordshire Treatments Policy describes the access and exclusion criteria which the Herefordshire CCG will apply to Procedures of Limited Clinical Value. The term Procedures of Limited Clinical Value (POLCV), refers to procedures and treatments that are of value, but only in the right clinical circumstances. The main objective for having these treatment policies is to ensure that: Patients receive appropriate health treatments in the right place and at the right time; Treatments with no or a very limited evidence base are not used; and Treatments with minimal health gain are restricted. The procedures, to which this relates, are listed in the Scope section below. THIS POLICY APPLIES TO ROUTINE, PLANNED CARE ONLY. FOR URGENT AND EMERGENCY CARE DIRECT REFERRAL TO SECONDARY AND TERTIARY SERVICES MAY BE APPROPRIATE. 2 BACKGROUND Herefordshire Clinical Commissioning Group (CCG) and Herefordshire County Council Public Health Commissioners have worked collaboratively to develop this core set of commissioning policies. The policy aims to ensure that Herefordshire approach is consistent with other CCGs following a review of policies across Bristol, Birmingham, Solihull and the Black Country, Shropshire, Staffordshire. This helps us to avoid variation in access to NHS services in different areas (which is sometimes called postcode lottery in the media) and allow fair and equitable treatment for all local patients. CCGs have limited budgets; these are used to commission healthcare that meets the reasonable requirements of its patients, subject to the CCG staying within the budget it has been allocated. By using these policies, we can prioritise resources using the best evidence about what is clinically effective, to provide the greatest proven health gain for the whole of the CCG s population. Our intention is to ensure access to NHS funding is equal and fair, whilst considering the needs of the overall population and evidence of clinical and cost effectiveness. In cases of diagnostic uncertainty, the scope of this policy does not exclude the clinician s right to seek specialist advice. This advice can be accessed through a variety of different mediums and can include both face to face specialist contact as well as different models of consultant and specialist nurse advice and guidance virtually. We recognise there may be exceptional circumstances where it is clinically appropriate to fund each of the procedures listed in this policy and these will be considered on a case-by-case basis. Funding for cases where either: a) the clinical threshold criteria is not met, or b) the procedure is not routinely funded, will be considered by the CCG following application to the CCG s Prior Approval Panel or Individual Funding Request Panel, whereby the application process will be applied. `

7 3 POLICY STATEMENT Commissioning decisions by CCG Commissioners are made in accordance with the commissioning principles set out below, and in the CCGs Individual Funding Request Policy: CCG Commissioners require clear evidence of clinical effectiveness before NHS resources are invested in the treatment. In doing so, the CCG will look to evidence from the National Institute for Clinical Effectiveness, Royal Colleges, the Public Health services and published research; CCG Commissioners require clear evidence of cost effectiveness before NHS resources are invested in the treatment; The cost of the treatment for this patient and others within any anticipated cohort is a relevant factor; CCG Commissioners will consider the extent to which the individual or patient group will gain a benefit from the treatment as well as the potential for harm to be caused by an intervention; CCG Commissioners will balance the needs of each individual against the benefit which could be gained by alternative investment possibilities to meet the needs of the community; CCG Commissioners will encourage patients to take a full part in decision making about what treatments they will receive, within the list of treatments that the CCG has agreed to fund; CCG Commissioners will consider all relevant national standards and take into account all proper and authoritative guidance; AND Where a treatment is approved CCG Commissioners will respect patient choice as to where a treatment is delivered. In determining the procedures that will be funded, the CCG will take into account the resources available to it. 4 GOVERNANCE AND AUTHORISATIONS CCGs are governed by section 14Z2 of the NHS Act 2006, Subsection 4 of the Act empowers NHS England to publish guidance on compliance with this section, which CCGs must have regard to. This was published in September 2013 (Transforming Participation in Health and Care: In summary, any significant commissioning decision or reconfiguration is caught by these statutory requirements. The statute does not insist on consultation, but seeks to make sure that service users are involved. In practice, for any significant proposed change to services, some form of consultation exercise will be required to comply with this duty. The Act requires that The Board must make arrangements to secure that individuals to whom the services are being or may be provided are involved (whether by being consulted or provided with information or in other ways). The Act also requires CCGs to set out how it will approach public involvement in its Constitution. HCCG Constitution can be found at ( The CCG has committed to ensuring that: ` Member practices are involved in decision making GP Parliament is consulted where appropriate Public and patients views are heard and their expectations understood and met as appropriate; The CCG builds and maintains an effective relationship with Local Healthwatch and draws on existing patient and public engagement and involvement expertise; AND The CCG has appropriate arrangements in place to secure public and patient involvement and responds in an effective and timely way to feedback and recommendations from patients, carers and the public.

8 HCCG Governing Body is responsible for the approval of this policy, HCCG Governing Body will be the sole body authorised to approve changes to this Policy. However it will delegate the authorisation of changes in the appendices to the Herefordshire CCG Clinical Executive, where the changes are: Amendments to eligibility criteria set by the National Institute for Health and Improvement (NICE); OR In line with recommendations on eligibility criteria made by other recognised national bodies (such as Royal Colleges); OR In line with recommendations made by NHSE following extensive engagement and/or consultation; In line with changes made by other CCGs where they have carried out extensive consultation prior to these being made, or where a significant number of CCGs have made these changes. OR Supported by the CCGs engagement and involvement structures and are not otherwise significant changes that would require formal engagement and/or consultation. Where a Quality Impact Assessment and/or Equality Impact Assessment shows potential adverse impact on any group of patients. With the following exceptions: Changes that could be determined as significant and which should be subject to local Consultation, regardless of the section above. Significant change will need to be determined by the Clinical Executive, which will take into account any issues raised in Equality and/or Quality Impact Assessments. 5 LIFESTYLE FACTORS AND SURGERY Lifestyle factors can have an impact on the functional results of some elective surgery. For example, smoking is known to affect the outcomes of some foot and ankle procedures, smoking and obesity increase the risk of post-operative complications, alcohol affects the body s ability to process medicines. Therefore, to ensure optimal outcomes, all patients who smoke or have a body mass index of 35 or greater and are being considered for referral to secondary care, will be strongly advised to access CCG and Local Authority Public Health commissioned smoking cessation and weight reduction management services prior to surgery. The CCGs guidance on Optimise Your Health before Surgery requires GPs and Providers to ensure that these patients have been offered access to these services and encouraged to use them. Patient engagement with these preventive services may influence the immediate outcome of surgery and/or impact on the amount of benefit that a patient gets from the procedure. While failure to quit smoking or lose weight will not be a contraindication for surgery, GPs and Surgeons should ensure patients are fully informed of the risks associated with the procedure in the context of their lifestyle and how changes to their lifestyle would benefit their health and, specifically, how the benefits of the procedure would be affected. 6 PSYCHOLOGICAL FACTORS AND SURGERY Commissioners acknowledge that there is a psychological dimension for patients in seeking or considering the option of treatment and surgery. However, as there are no universally accepted and objective measures of psychological distress, such factors are not taken into account in any policy clinical thresholds. Nevertheless, where a clinician believes that a condition is leading to severe psychological distress s/he may submit on behalf of the patient an IFR or Prior Approval application. The IFR or Prior Approval Panel may seek a formal psychological or psychiatric assessment to aid its decision making. `

9 7 SCOPE This Policy refers to patients whose treatment is funded by Herefordshire CCG only. Patients whose care is funded by other CCGs or Welsh Health Boards will have decisions about treatments guided by their local policies. The procedures set out in Appendix 1 are within the scope of this policy, each procedure is categorised as either not routinely funded or restricted these are defined as follows: Not routinely funded - This means the CCG will only fund the treatment if an Individual Funding Request (IFR) or Prior Approval application proves exceptional clinical need and that application is supported by the CCG. Restricted - This means that the CCG will only fund treatments if the patient meets the stated clinical threshold for care and where the patient meets the required clinical criteria. For patients not meeting the criteria this means the CCG will only fund the treatment if a Prior Approval Process application proves exceptional clinical need and that application is supported by the CCG. Appendix 1 covers the following specialties: Cosmetic Surgery (including Dermatology and Plastic Surgery) Equipment Ear Nose & Throat procedures General Surgery Mental Health Musculo-Skeletal Health Neurology/Neurosurgery Obstetrics and Gynaecology Ophthalmology Oral Surgery Other Procedures and Treatments Pain Urology Appendix 2 covers Medicines Optimisation and advice to prescribers in an A-Z reference list which has been developed using local and national reference sources. It clarifies commissioning intentions for the prescribing of medications across Herefordshire to ensure that prescribing is evidence based, offers best value for money for the NHS and is safe and equitable for patients. Herefordshire CCG subscribes to PrescQIPP 1 an organisation which provides evidence-based medicines optimisation support. Their aim is to help NHS organisations to improve medicines-related care, through the provision of robust, accessible and evidence-based resources. One role of PrescQIPP is to review drugs which have limited clinical value and offer guidance to NHS organisations on prescribing recommendations for these. Their original document, DRugs Of low Priority (DROP) was first published in 2012 and was an accumulation of medicines considered being low priority, poor value for money or for which there were safer alternatives. The DROP-List is now rebranded as Drugs to Review to Optimise Prescribing 2 and has been updated to include drugs prescribed across the NHS that are considered low priority and poor value for money and also some of the NICE do not do items. It also incorporates drugs which can be provided as self-care, with advice and support from the community pharmacists, and discusses the potential to support medicines optimisation for the drugs listed. 1 PrescQIPP available at PrescQIPP - PrescQIPP 2 Drug Tariff available at Drug Tariff NHSBSA `

10 The PrescQIPP evidenced-based resources are produced predominantly by medicines information pharmacists currently working within NHS Trusts. This provides a comprehensive literature search approach to their guidance based on national guidance, including NICE, and other clinical evidence. This evidence and guidance is reviewed to produce the DROP-List, for drugs which have limited clinical evidence for their use on the NHS Medicines optimisation is key to achieving the best outcomes for patients. The Royal Pharmaceutical Society 3 good practice guide on medicines optimisation suggests the following principles are key to help patients get the most out of their medicines. These principles would apply when reviewing drugs in the DROP-List and any locally made decisions of additions to the CCG Treatments Policy in relation to medicines: Treatments of limited clinical value are not used and medicines no longer required are stopped. Optimal patient outcomes are obtained from choosing a medicine using best evidence (for example, following NICE guidance, local formularies etc.) and these outcomes are measured. Medicines wastage is reduced. The NHS achieves greater value for money invested in medicines. Patients are more engaged, understand more about their medicines and are able to make choices, including choices about prevention and healthy living. It becomes routine practice to signpost patients to further help with their medicines and to local patient support groups. Incidents of avoidable harm from medicines are reduced. Further references are integrated into the Herefordshire Medicines List: Prescribing of Unlicensed Medicines Substances not in the Advisory Committee on Borderline Substances (ACBS) List AND Items available on NHS FP10 Prescription but which are not normally recommended in Herefordshire referencing the Local Joint Medicines formulary. Appendix 3 includes the process and information needed to undertake a Prior Approval or Individual Funding Request (IFR). Appendix 4 includes the form for a Prior Approval application. Appendix 5 includes the form for an Individual Funding Request (IFR). 8 IMPLEMENTATION GPs, service providers and clinical staff treating CCG funded patients are expected to implement this policy. The decision and rationale to provide a treatment contained within this policy should be clearly documented within the clinical notes together with an explanation of which criteria apply. This request allows the CCG to ensure that it is funding treatments that fall within its policies and that it is not funding treatments that have not been agreed. 3 Herefordshire Joint Drugs Formulary available at Home - Herefordshire CCG `

11 GPs and clinical staff treating patients are also encouraged to consult the CCGs list of previous decisions relating to Individual Funding Requests, to inform their discussions with patients. This list is available by contacting the CCG at the address below. The guidance contained in this policy is also appended to the CCG EMIS Web e-referral templates which have been previously distributed to practices. GPs and other referring clinicians are asked to make use of these templates when referring patients to WVT. Where a treatment is listed in this document and treatment is provided to a patient, the CCG will not pay for a procedure that is Not Routinely Funded unless there is a Prior Approval or IFR panel approval. The IFR policy can be found at ( The CCG will be entitled to decline payment for Restricted procedures unless it has clear evidence that the exception criteria have been applied and recorded in the medical record. Patients with problems or conditions that require treatments included in this policy should be referred to a consultant or specialist only after a clinical assessment is made by the GP or consultant; AND the patient meets all the criteria set out in the policy. GPs and consultants wishing to seek a specialist opinion for patients who meet the above criteria should ensure the essential clinical information is included in the referral letter confirming the patient has been assessed in line with this policy. `

12 The CCG recognizes that there will be exceptional individual circumstances when funding for treatments included within this treatment policy. Herefordshire CCG has two exceptionality funding application processes Prior Approval and Individual Funding Request Prior Approval Treatments that are restricted/criteria based: Exceptionality requests for funding for patients that do not meet the clinical criteria but where there are exceptional clinical circumstances, the clinician is entitled to request on behalf of their patient individual funding for a particular treatment this request is called a Prior Approval Request and will be assessed at the Prior Approval Meeting to decide if funding will be approved. Treatments that are not routinely funded: Exceptionality requests for existing treatments for a patient whose clinical circumstances do not currently qualify them for funding under the existing commissioning policy but where there are exceptional clinical circumstances, the clinician is entitled to request individual funding using the Prior Approval Request application. This request will be assessed at the Prior Approval Meeting to decide if funding will be approved. Individual Funding Requests For requests for funding an existing treatment experimentally for one or more patients with a rare clinical condition or rare clinical circumstances or to enter into a clinical trial, the clinician is entitled to complete an Individual Funding Request which will be submitted to Individual Funding Request Panel to determine if the patient has individual circumstances are exceptional and decide if funding will be approved. Prior Approval Requests should only be sent to Iptpa.hccg@nhs.net Individual Funding Requests should only be sent to the NHS.net account as below. Guidance regarding Prior Approval and IFRs requests and an application form can be found on the CCG s website. IFR contact information follows, however please refer to the CCG IFR policy for more information. Address: Prior Approval/IFR Case Manager NHS Herefordshire CCG St Owen s Chambers 22 St Owen Street Hereford Herefordshire HR1 2PL Telephone: ifr.hereford@nhs.net `

13 9 MONITORING AND REVIEW This policy will be subject to continued monitoring using a mix of the following approaches: Prior approval process Audits of referrals and of the management of referrals Post activity monitoring through routine data Post activity monitoring through case note audits This policy will be kept under regular review, to ensure that it reflects developments in the evidence base regarding clinical and cost effectiveness. 10 COPIES OF THIS POLICY Electronic copies of this policy can be found on the CCG website Alternatively, you may contact the CCG and ask for a copy of the Herefordshire Treatments Policy. Copies of the policy will be distributed to all providers and general practices. `

14 11 GLOSSARY OF TERMS TERM MEANING Abdominoplasty/Apronectomy A procedure to reduce excess skin and fat, improve abdominal contours and scars, and tighten muscles. This is sometimes called a tummy tuck. Active treatment Treatment and care to manage a particular disease / condition, e.g. cancer treatment, renal dialysis. Adenoidectomy A procedure to remove the adenoids lumps of tissue at the back of the nose. Aesthetics These are procedures which relate to cosmetic procedures which are intended to restore or improve a person s appearance. Alopecia Hair loss. Analgesics Painkillers. Asymptomatic Without symptoms. Augmentation Increasing in size, for example breast augmentation. Benign Does not invade surrounding tissue or spread to other parts of the body; it is not a cancer. Binocular vision Vision in both eyes. Body Mass Index (BMI) Body Mass Index - a measure that adults can use to see if they are a healthy weight for their height. BWH Birmingham Women s Hospital NHS Foundation Trust. Cataract When the lens of an eye becomes cloudy and affects vision. CCG Clinical Commissioning Group. CCGs are groups of General Practices that work together to plan and design local health services in England. They do this by 'commissioning' or buying health and care services. Cholecystectomy Removal of the gall bladder. Chronic Persistent. Co-morbidities Other risk factors alongside the primary problem. Congenital Present from birth. Conservative treatment The management and care of a patient by less invasive means; these are usually non-surgical. Depilation Removal. For example hair depilation. DOH Department of Health. Eligibility/Threshold Whether someone qualifies. In this case, the minimum criteria to access a procedure. Exceptional clinical circumstances A patient who has clinical circumstances which, taken as a whole, are outside the range of clinical circumstances presented by a patient within the normal population of patients, with the same medical condition and at the same stage of progression as the patient. Functional health problem/difficulty/impairment Difficulty in performing, or requiring assistance from another to perform, one or more activities of daily living. Ganglion A non-cancerous fluid filled lump. GP General Practitioner.

15 TERM Gynaecomastia Haemorrhoidectomy Histology Hyperhidrosis Hysteroscopy Individual Funding Request (IFR) MEANING Benign enlargement of the male breast. A procedure to cut away haemorrhoids, sometimes called piles. The structure of cells or tissue under a microscope. Excess sweating. A hysteroscopy is a procedure used to examine the inside of the womb (uterus) using a hysteroscope (a narrow telescope with a light and camera at the end. Images are sent to a monitor so your doctor or specialist nurse can see inside your womb). A request received from a provider or a patient with explicit support from a clinician, which seeks funding for a single identified patient for a specific treatment which would otherwise not be routinely funded. Irreducible Unable to be reduced. Labiaplasty A procedure to reduce and/or reshape the labia. Lipomata Fat deposits under the skin. Liposuction A procedure using a suction technique to remove fat from specific areas of the body. Malignant/malignancy Harmful. Mastopexy A reconstructive procedure to lift the breast. Menorrhagia Abnormally heavy or prolonged bleeding at menstruation. Monocular vision Vision in one eye only. Multi-disciplinary Involving several professional specialisms for example in a Multi-disciplinary team (MDT). NICE guidance The guidance published by the National Institute for Health and Care Excellence. Not routinely funded (a This means the CCG will only fund the treatment if an procedure) Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. NSAIDS Non-steroidal anti-inflammatory drugs medication that reduces pain, fever and inflammation. Paediatric(ian) Medical care concerning infants, children and adolescents usually under 18. Pathology/pathological The way a disease or condition works or behaves. This may for example include examination of bodily fluids or tissue e.g. blood testing. PCT Primary Care Trust (PCTs were abolished on 31 March 2013, and replaced by Clinical Commissioning Groups). Pinnaplasty A procedure to pin or correct deformities the ear. PLCV Procedures of Lower Clinical Value; routine procedures that are of value, but only in the right circumstances. Precipitates Brings about/triggers. Primary care A patient s first point of interaction with NHS services e.g. a GP surgery. Prophylactic Preventative or prevention. Rationale Restricted (a procedure) Explanation of the reason why. This means CCG will fund the treatment if the patient meets the stated clinical threshold for care. 11

16 TERM MEANING Rhinophyma A condition causing development of a large, bulbous, ruddy (red coloured), nose. Rhinoplasty A procedure to shape the size and/or shape of the nose. Rhytidectomy A procedure to restore facial appearance or function. These are sometime called face or brow lifts. Secondary care Services provided by medical specialists, who generally do not have the first contact with a patient e.g. Hospital services. Stakeholders Individuals, groups or organisations who are or will be affected by this consultation, e.g. patients who currently use the service, carers, specific patient groups, etc. Symptomatic Something causing or exhibiting symptoms. Tonsillectomy A procedure to remove the tonsils. Vaginoplasty A procedure to reconstruct the vaginal canal. 12

17 APPENDIX 1 Herefordshire CCG APPENDICES TO THE HEREFORDSHIRE TREATMENT POLICY 13

18 APPENDIX 1 - TREATMENT PROCEDURES SECTION CONTENTS A.1 Cosmetic Surgery (Including Dermatology and Plastic Surgery) A.2 Equipment A.3 Ear Nose and Throat A.4 General Surgery A.5 Mental Health A.6 Musculoskeletal A.7 Neurology/Neurosurgery A.8 Obstetrics and Gynaecology A.9 Ophthalmology A.10 Oral Surgery A.11 Other Treatments and Procedures A.12 Pain A.13 Urology 14

19 FULL LIST OF PROCEDURES Procedure Ref SPECIALITY/PROCEDURE CCG POLICY A1 COSMETIC SURGERY (including Dermatology and Plastic Surgery) A1.1 Abdominoplasty / Apronectomy Restricted A1.2 Alopecia (Hair Loss) (Surgical Treatments) Not routinely funded A1.3 Blepharoplasty, Ptosis and Brow Lift - Eyelid Restricted Surgery (Upper and Lower) A1.4 Botulinum Toxin Treatments (Botox) for the face Not routinely funded A1.5 Breast Augmentation Restricted A1.6 Breast Reduction Restricted A1.7 Gynaecomastia (Male Breast Reduction) Restricted A1.8 Haemangioma Restricted A1.9 Hair Grafting male pattern baldness Not routinely funded A1.10 Hirsutism (Hair Depilation) Restricted A1.11 Hyperhidrosis (Botulinum toxin treatment) Not routinely funded A1.12 Inverted Nipple Correction Restricted A1.13 Labiaplasty (non-trauma) Not routinely funded A1.14 Lipoma Restricted A1.15 Liposuction Not routinely funded A1.16 Mammoplasty Revision (including prosthetic Restricted removal or replacement) A1.17 Mastopexy (Breast Lift) Not routinely funded A1.18 Other Cosmetic Procedures Not routinely funded A1.19 Penile Implants Not routinely funded A1.20 Pinnaplasty Not routinely funded A1.21 Removal/Repair of Ear Lobes Restricted A1.22 Resurfacing Procedures: Dermabrasion, Chemical Peels and Laser Treatment Not routinely funded A1.23 Rhinoplasty Restricted A1.24 Rhinophyma Not routinely funded A1.25 Rhytidectomy Restricted A1.26 Scars and Keloids - Medical and Surgical Treatment Restricted A1.27 Skin Lesions Surgical removal of benign (noncancerous) Restricted A1.28 Tattoos - Surgical Removal of correction of body Not routinely funded piercings and correction of respective problems A1.29 Thigh Lift, Buttock Lift and Arm lift, Excision of Redundant Skin or Fat Restricted A1.30 Thread / Telangiectasis / Reticular Veins Not routinely funded A1.31 Vaginoplasty Restricted A1.32 Viral warts Restricted A.2 EQUIPMENT A2.1 Wheelchairs Restricted A2.2 Wigs Restricted 15

20 A.3 EAR NOSE & THROAT PROCEDURES A3.1 Adenoidectomy Restricted A3.2 Bone anchored Hearing Aids NHS England A3.3 Chronic Rhinosinusitis: Functional endoscopic sinus surgery Restricted A3.4 Chronic Rhinosinusitis: Balloon catheter dilation of Not routinely funded paranasal sinus ostia A3.5 Grommets Restricted A3.6 Snoring (with Obstructive Sleep Apnoea) Not routinely funded A3.7 Tonsillitis Restricted A.4 GENERAL SURGERY A4.1 Bariatric Surgery Not routinely funded A4.2 Cholecystectomy For Asymptomatic Gallstones Not routinely funded A4.3 Circumcision Restricted A4.4 Endoscopic Radiofrequency Ablation For Gastric Not routinely funded A4.5 Haemorrhoidectomy Restricted A4.6 Inguinal (Groin) Hernia Repair Restricted A4.7 Linx Procedure For Gastric Reflux Not routinely funded A4.8 Lymph Node Transplant Post Mastectomy Restricted A4.9 Varicose Veins Restricted A4.10 Vascular Lower Limb Arterial Procedures Restricted A4.11 Venous Angioplasty For Multiple Sclerosis Not routinely funded A.5 MENTAL HEALTH A5.1 Borderline Personality Disorder - Therapeutic Community Treatment Method Not routinely funded A5.2 Liothyronine Position Statement Not routinely funded A.6 MUSCULOSKELETAL HEALTH A6.1 Acromio Clavicular Joint Excision Or Surgical Restricted A6.2 Decompression Of Subacromial Space Back Pain - Non Specific, Specific And Chronic Restricted (See Also Management Of Pain) A6.3 Carpal Tunnel Syndrome Restricted #Hysteros Dupuytren s Disease/Contracture Restricted A6.5 Foot Treatments Restricted A6.6 Ganglion Restricted A6.7 Hip Arthroscopy For Femuro-Acetabular Not routinely funded A6.8 Hip Replacement Surgery Restricted A6.9 Hip Resurfacing Techniques (Primary Resurfacing Restricted Arthroplasty Of The Joint) A6.10 Joint Injections Site Of Procedure Restricted A6.11 Knee Arthroscopy Restricted A6.12 Knee Autologous Cartilage Transplantation Not routinely funded A6.13 Knee Replacement Surgery Restricted A6.14 Spinal Fusion For Low Back Pain Restricted A6.15 Trigger Finger Restricted A.7 NEUROLOGY/NEUROSURGERY A7 Inpatient Neuro-Rehabilitation Restricted 16

21 A.8 OBSTETRICS and GYNAECOLOGY A8.1 Caesarian Section for Non-Clinical Reasons Restricted A8.2 Dilation and Curettage (D&C) for Menorrhagia Not routinely funded (Heavy Menstrual Bleeding) A8.3 Doppler Ultrasound of Umbilical and Uterine Artery Not routinely funded in Antenatal Care A8.4 Hysterectomy +/- Oopherectomy Restricted A8.5 Hysteroscopy for Menorrhagia Restricted A8.6 Infertility Treatment Restricted A8.7 Reversal of Female Sterilisation Not routinely funded A.9 OPHTHALMOLOGY A9.1 Cataract Surgery Restricted A9.2 Laser (Photorefractive) Surgery for Short Sight Not routinely funded A.10 ORAL SURGERY A10.1 Apicectomy Restricted A10.2 Cosmetic Dental Procedures Not routinely funded A10.3 Orthodontic Treatment Restricted A10.4 Wisdom Tooth Removal Restricted A.11 OTHER PROCEDURES and TREATMENTS A11.1 Chronic Fatigue Syndrome/Myalgic Not routinely funded A11.2 Complementary Medicines and Therapies Restricted A11.3 Hyperbaric Oxygen Therapy Restricted A.12 PAIN A12.1 Epidural Injections (Lumbar and Caudal), Facet Restricted Joint Injections for Lower Back Pain, Medial Branch Block A12.2 Prolotherapy Not routinely funded A12.3 Radiofrequency and Electrothermal Ablation for Restricted Chronic Back Pain A12.4 Spinal Cord Stimulation and Chronic Pain Restricted A.13 UROLOGY A13.1 Male circumcision Restricted A13.2 Medicines for Erectile Dysfunction Restricted A13.3 Penile Implants Not routinely funded A13.4 Reversal of Male Sterilisation Not routinely funded 17

22 SECTION A.1 Surgery) COSMETIC SURGERY (Including Dermatology and Plastic Procedure Ref SPECIALITY/PROCEDURE CCG POLICY Application Process A.1 COSMETIC SURGERY (including Dermatology and Plastic Surgery) A1.1 Abdominoplasty / Apronectomy Restricted Prior Approval A1.2 Alopecia (Hair Loss) (Surgical Treatments) Not routinely funded Prior Approval A1.3 Blepharoplasty, Ptosis and Brow Lift - Eyelid Surgery (Upper and Lower) Restricted Prior Approval A1.4 Botulinum Toxin Treatments (Botox) for the Not routinely funded Prior Approval A1.5 Breast Augmentation Restricted Prior Approval A1.6 Breast Reduction Restricted Prior Approval A1.7 Gynaecomastia (Male Breast Reduction) Restricted Prior Approval A1.8 Haemangioma Restricted Prior Approval A1.9 Hair Grafting male pattern baldness Not routinely funded Prior Approval A1.10 Hirsutism (Hair Depilation) Restricted Prior Approval A1.11 Hyperhidrosis (Botulinum toxin treatment) Not routinely funded Prior Approval A1.12 Inverted Nipple Correction Restricted Prior Approval A1.13 Labiaplasty (non-trauma) Not routinely funded Prior Approval A1.14 Lipoma Restricted Prior Approval A1.15 Liposuction Not routinely funded Prior Approval A1.16 Mammoplasty Revision (including prosthetic removal or replacement) Restricted Prior Approval A1.17 Mastopexy (Breast Lift) Not routinely funded Prior Approval A1.18 Other Cosmetic Procedures including revision Not routinely funded Prior Approval of previous cosmetic procedures A1.19 Penile Implants Not routinely funded Prior Approval A1.20 Pinnaplasty Not routinely funded Prior Approval A1.21 Removal/Repair of Ear Lobes Restricted Prior Approval A1.22 Resurfacing Procedures: Dermabrasion, Chemical Peels and Laser Treatment Not routinely funded Prior Approval A1.23 Rhinoplasty Restricted Prior Approval A1.24 Rhinophyma Not routinely funded Prior Approval A1.25 Rhytidectomy Restricted Prior Approval A1.26 Scars and Keloids - Medical and Surgical Restricted Prior Approval A1.27 Skin Lesions Surgical removal of benign (non-cancerous) Restricted Prior Approval A1.28 Tattoos - Surgical Removal of correction of body piercings and correction of respective A1.29 Thigh Lift, Buttock Lift and Arm lift, Excision of Redundant Skin or Fat Not routinely funded Prior Approval Restricted Prior Approval A1.30 Thread / Telangiectasis / Reticular Veins Not routinely funded Prior Approval A1.31 Vaginoplasty Restricted Prior Approval A1.32 Viral warts Restricted Prior Approval 18

23 LIFESTYLE FACTORS AND SURGERY Lifestyle factors can have an impact on the functional results of some elective surgery. For example, smoking is known to affect the outcomes of some foot and ankle procedures, smoking and obesity increase the risk of post-operative complications, alcohol affects the body s ability to process medicines. Therefore, to ensure optimal outcomes, all patients who smoke or have a body mass index of 35 or greater and are being considered for referral to secondary care, will be strongly advised to access CCG and Local Authority Public Health commissioned smoking cessation and weight reduction management services prior to surgery. The CCGs guidance on Optimise Your Health before Surgery requires GPs and Providers to ensure that these patients have been offered access to these services and encouraged to use them. Patient engagement with these preventive services may influence the immediate outcome of surgery and/or impact on the amount of benefit that a patient gets from the procedure. While failure to quit smoking or lose weight will not be a contraindication for surgery, GPs and Surgeons should ensure patients are fully informed of the risks associated with the procedure in the context of their lifestyle and how changes to their lifestyle would benefit their health and, specifically, how the benefits of the procedure would be affected. PSYCHOLOGICAL FACTORS AND SURGERY Commissioners acknowledge that there is a psychological dimension for patients in seeking or considering the option of treatment and surgery. However, as there are no universally accepted and objective measures of psychological distress, such factors are not taken into account in any policy clinical thresholds. Nevertheless, where a clinician believes that a condition is leading to severe psychological distress s/he may submit on behalf of the patient an IFR or Prior Approval application. The IFR or Prior Approval Panel may seek a formal psychological or psychiatric assessment to aid its decision making. 19

24 A1.1 Abdominoplasty Or Apronectomy Abdominoplasty and apronectomy (Tummy Tuck) are surgical procedures performed to remove excess fat and skin from the mid and lower abdomen. Many people develop loose abdominal skin after pregnancy or substantial weight loss, whether due to surgical or dietary weight loss. CCG Policy Category Restricted Application Process Prior Approval (see appendix 3) This means that the CCG will only fund treatments for patients where the required criteria are met. For patients not meeting the criteria this means the CCG will only fund the treatment if a Prior Approval Process application proves exceptional clinical need and that application is supported by the CCG. Guidance The Prior Approval Review Panel will take account of the following criteria: Documented evidence of clinical pathology due to the excess of overlying skin e.g. recurrent infections, intertrigo which has led to ulceration requiring repeated courses of treatment for a minimum period of one year or disability resulting in severe restrictions in activities of daily living AND The patients BMI before weight loss must have been 40kg/m2 or above AND The patients BMI must be < 28 kg/m2 and has been within this range for 1 year as measured and recorded by the NHS. In some patients this may not be achievable due to the weight of excess skin - in such cases the patient must have lost 50% of their excess weight and the clinician must confirm that further reduction in BMI will not be possible without removal of excess skin AND An abdominoplasty / apronectomy has not already been performed. This is because purely removal of surplus skin or fat irrespective of site on body is deemed to be cosmetic and does not meet the principles laid out in this policy. Applicable OPCS Codes Applicable OPCS Codes S02.1/.2/.8/.9 20

25 A1.2 Alopecia (Surgical Treatments) Alopecia refers to hair loss on either the head or the body although typically at least the head will be involved. CCG Policy Category Not routinely funded Application Process Prior Approval (see appendix 3) This means the CCG will only fund the treatment if a Prior Approval Process application proves exceptional clinical need and that application is supported by the CCG. Guidance References Surgical treatment for hair loss is deemed to be cosmetic and does not meet the principles laid out in this policy. The British Association Dermatologists state Leaving alopecia areata untreated is a legitimate option for many patients. Spontaneous remission occurs in up to 80% of patients with limited patchy hair loss of short duration (< 1 year). Such patients may be managed by reassurance alone, with advice that regrowth cannot be expected within 3 months of the development of any individual patch. The NHS Choices guidance below provides a range of non-surgical options for hair loss, including prescription medication from the GP. British Association of Dermatologists - Guidelines for the management of alopecia areata (2012) Weblink: British Association of Dermatologists - alopecia areata patient information leaflet Weblink: NHS Choices Guide to Hair Loss Treatment Weblink: Applicable OPCS Codes ICD 10 L63. S21.1/.2/.8/.9; S33.1/.2/.3/.8/.9 21

26 A1.3 Blepharoplasty, Ptosis And Brow Lift - Eyelid Surgery (Upper And Lower) Blepharoplasty is a surgical procedure performed to correct puffy bags below the eyes and droopy upper eyelids. It can improve appearance but also has profound functional effects on patients, widening the field of peripheral vision, as well as reducing irritation from eyelashes, and sometimes chronic pain from compensating muscular over action. Blepharoplasty type procedures may form part of the treatment of pathological conditions of the lid or overlying skin and not for cosmetic reasons. This procedure may be commissioned by the NHS to correct functional impairment. Surgery on the upper eyelid (upper lid blepharoplasty) Many people acquire excess skin in the upper eyelids as part of the process of ageing and this may be considered normal. However if this starts to interfere with vision or function of the eyelid then this can warrant treatment. Excess upper eyelid skin is quite distinct from ptosis of the eyelid, where pathological drooping of the eyelid leads to interference in peripheral and sometimes central vision. In addition, in many cases, patients are referred for consideration of upper eyelid surgery, when, following expert assessment, they have a brow ptosis leading to their functional symptoms. In such a situation, brow surgery would be advised, not blepharoplasty. Excessive skin in the lower lid may cause eye bags but does not affect function of the eyelid or vision and therefore does not need correction. CCG Policy Category Restricted Application Process Prior Approval (see appendix 3) This means that the CCG will only fund treatments for patients where the required criteria are met. For patients not meeting the criteria this means the CCG will only fund the treatment if a Prior Approval Process application proves exceptional clinical need and that application is supported by the CCG. 22

27 CCG Policy The following eyelid surgery procedures will not be funded unless patients have functional symptoms such as interference with their vision, or eye irritation: Surgery for cosmetic reasons Surgery for cyst of moll Surgery for cyst of zeis Removal of eyelid papillomas or skin tags Surgery for pingueculum Excision of other suspected benign lid lumps Upper eyelid blepharoplasty, treatment for Ptosis and Brow lift Treatment will be funded only for those patients who have functional symptoms, i.e. an impairment in their vision (central or peripheral), or irritation as a result of the condition (e.g. due to inturning eyelashes or chronic brow overaction) Lower Eyelid blepharoplasty will not be funded. The CCG recognizes that the following conditions are not cosmetic and will fund the correction of: ectropion (eyelid turned outwards from the eyeball), and/or entropion (eyelid folds into the eyeball) This is because all eyelid surgery procedures are deemed to be cosmetic and do not meet the principles laid out in the Cosmetic Surgery policy. Guidance Removal of Benign (non-cancerous) or Congenital Skin Lesions that does not meet the criteria below is deemed to be cosmetic and does not meet the principles laid out in the Cosmetic Surgery policy unless there are clear clinical symptoms significantly affecting the patient s vision/visual field (see upper and lower eyelid surgery categories below). For patients who either DO NOT meet the eligibility criteria below or require treatment for cosmetic reasons, this means the CCG will only fund the treatment if a Prior Approval Process application proves exceptional clinical need and that application is supported by the CCG. 23 Upper eyelid blepharoplasty, treatment for Ptosis and Brow lift This procedure is restricted. The CCG will fund this treatment if the patient meets the required criteria: Impairment of vision in the relaxed, non-compensated state as determined by the Visual field test reducing visual field to less than 60 laterally in either direction from fixation or to less than 40 vertically from fixation in either eye OR Congenital (from birth) ptosis (drooping of the upper eyelid) OR Chalazion (meibomian cyst) - unless acutely infected, it is harmless and nearly all resolve if given enough time. However if conservative therapy fails, chalazia can be treated by surgical incision into the tarsal gland followed by curettage of the retained secretions and

28 inflammatory material under local anaesthetic. This criterion applies to ptosis as well as brow lift cases. Eyelid surgery will not be commissioned for purely cosmetic reasons. References Royal College of Surgeons Blepharoplasty Guide Weblink: download/file NHS Choices Cosmetic Surgery Procedures Weblink:` Applicable OPCS Codes ICD 10 H02.4 C13.1/.2/.3.4/.5/.8/.9; C16.1/.2/.3/.4/.5/.8/.9, C18. 1/.2/.3.4/.6/.8/.9 S01.4/.5/.6 24

29 A1.4 Botulinum Toxin Injection For The Ageing Face Botulinum toxin A is a powerful neurotoxin which is used medically to relax muscles and for certain conditions there are recognised clinical benefits to patients. However, due to its mechanism of action botulinum toxin A can be used for medical conditions for which the clinical benefits have not been proven or are unclear and inconsistencies have arisen before this policy existed. Botulinum toxin injections, such as Botox, are used to help relax facial muscles and make lines and wrinkles less obvious. During the procedure, the skin is cleaned and small amounts of botulinum toxin are injected into the area to be treated. Several injections are usually needed at different sites. The injections usually take effect about three to five days after treatment and it can take up to two weeks for the full effect to be realised. The effects generally last for about three to four months. CCG Policy Category Not routinely funded Application Process Prior Approval (see appendix 3) This means the CCG will only fund the treatment if a Prior Approval Process application proves exceptional clinical need and that application is supported by the CCG. Guidance Botulinum Toxin Injection for the ageing face will not be routinely commissioned. This is because Botulinum Toxin Injection for the ageing face is deemed to be cosmetic and does not meet the principles laid out in this policy. The use of botulinum toxin for treatments other than the face is listed against the relevant conditions. If a condition is not contained in this policy a Prior approval application should be made. References NHS Choices Guide to Non-surgical cosmetic procedures Weblink: Applicable OPCS Codes ICD 10 Z41.1 X85.1, Z