Treatment Policies. NHS Birmingham South Central CCG Governing Body Date Issued: 7 September 2016 Name of Responsible Board / Committee for Revision:

Transcription

1 PAPER 10.1 Clinical Commissioning Group (CCG) Treatment Policy NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Treatment Policies Name of Responsible Board / Committee NHS Solihull CCG Governing Body for Ratification: Date Issued: 3 August 2016 Name of Responsible Board / Committee for Revision: Birmingham and Solihull CCGs Clinical Policies Quality and Safety Sub-Committee Date Revised: 9 November 2017 Review Date: March 2019 Name of Responsible Board / Committee for Ratification: NHS Birmingham South Central CCG Governing Body Date Issued: 7 September 2016 Name of Responsible Board / Committee for Revision: Birmingham and Solihull CCGs Clinical Policies Quality and Safety Sub-Committee Date Revised: 9 November 2017 Review Date: March 2019 Name of Responsible Board / Committee NHS Birmingham CrossCity CCG Governing Body for Ratification: Date Issued: 20 September 2016 Name of Responsible Board / Committee for Revision: Birmingham and Solihull CCGs Clinical Policies Quality and Safety Sub-Committee Date Revised: 9 November 2017 Review Date: March 2019 Name of Responsible Board / Committee for Revision: Sandwell and West Birmingham CCG Quality and Safety Committee Date Revised: 19 th February 2018 Review Date: March 2019 Page 1 of 100

2 PAPER 10.1 Clinical Commissioning Group (CCG) Treatment Policy Contents INTRODUCTION... 4 BACKGROUND... 4 SCOPE... 6 IMPLEMENTATION... 8 MONITORING and REVIEW... 9 COPIES OF THIS POLICY... 9 GLOSSARY OF TERMS Policy for Adenoidectomy Policy for Cosmetic Surgery Abdominoplasty/Apronectomy Thigh Lift, Buttock Lift and Arm Lift, Excision of Redundant Skin or Fat Liposuction Breast Augmentation Breast Reduction Mastopexy Inverted Nipple Correction Surgery for Gynaecomastia Labiaplasty Vaginoplasty Pinnaplasty Repair of Ear Lobes Rhinoplasty; Setoplasty & Septo-Rhinoplasty Face Lift or Brow Lift (Rhytidectomy) Hair Depilation (removal) Alopecia (Hair Loss) Removal of Tattoos/Surgical correction of body piercings and correction of respective problems 31 Removal of Benign (non-cancerous) or Congenital Skin Lesions Removal of Lipomata Medical and Surgical treatment of Scars and Keloids Botulinum Toxin Injection for the Ageing Face Treatment for Viral Warts Thread/ Telangiectasis/ Reticular veins (Spider Angiomas) Rhinophyma (bulbous, red nose) Resurfacing Procedures: Dermabrasion, Chemical Peels and Laser Treatment Other Cosmetic Procedures Revision of Previous Cosmetic Surgery Procedures Policy for Low Back Pain and Radicular (Sciatic) Pain Policy for Botulinum Toxin for Hyperhidrosis Policy for Cataracts Policy for Cholecystectomy for Asymptomatic Gallstones Policy for Male Circumcision Policy for Dilation and Curettage (D&C) for Menorrhagia Policy for Eyelid Surgery (Upper and Lower) Policy for Ganglion Policy for Groin Hernia Repair Policy for Grommets Policy for Haemorrhoidectomy Policy for Hip Replacement Surgery Policy for Hysterectomy for Heavy Menstrual Bleeding Page 2 of 100

3 Policy for Diagnostic Hysteroscopy for Menorrhagia Policy Policy for Knee Replacement Surgery Policy for Penile Implants Policy for Tonsillectomy Policy for Trigger Finger Policy for Varicose Veins Page 3 of 100

4 INTRODUCTION The purpose of this policy is to describe the access and exclusion criteria which the CCGs listed below will apply to Harmonised Treatment Policies. The term Harmonised Treatment Policies, refers to procedures and treatments that are of value, but only in the right clinical circumstances. The main objective for having 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. BACKGROUND The following Clinical Commissioning Groups (CCG) and their respective Local Authority Public Health Commissioners have worked collaboratively to develop this harmonised core set of commissioning policies: NHS Birmingham CrossCity CCG NHS Birmingham South Central CCG NHS Sandwell and West Birmingham CCG NHS Solihull CCG The policy aims to improve consistency by bringing together the different policies across Birmingham, Solihull and the Black Country into one common set. This helps us to stop 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 commissioned, will be considered by the CCGs following application to the CCG s Individual Funding Request Panel, whereby the IFR process will be applied. Page 4 of 100

5 This position is supported by each CCG s Ethical Framework which can be found on the respective CCG website. PRINCIPLES Commissioning decisions by CCG Commissioners are made in accordance with the commissioning principles set out below, and in the Birmingham, Black Country and Solihull CCGs Individual Funding Request Policy: 1. CCG Commissioners require clear evidence of clinical effectiveness before NHS resources are invested in the treatment; 2. CCG Commissioner require clear evidence of cost effectiveness before NHS resources are invested in the treatment; 3. The cost of the treatment for this patient and others within any anticipated cohort is a relevant factor; 4. CCG Commissioners will consider the extent to which the individual or patient group will gain a benefit from the treatment; 5. 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; 6. CCG Commissioners will consider all relevant national standards and take into account all proper and authoritative guidance; and 7. Where a treatment is approved CCG Commissioners will respect patient choice as to where a treatment is delivered. LIFESTYLE FACTORS AND SURGERY Lifestyle factors can have an impact on the functional results of some elective surgery. In particular, smoking is well known to affect the outcomes of some foot and ankle procedures. In addition, many studies have shown that the rates of postoperative complications and length of stay are higher in patients who are overweight or who smoke. Therefore, to ensure optimal outcomes, where commissioned, all patients who smoke or have a body mass index of 35 or greater and are being considered for referral to secondary care, should be able to access CCG and Local Authority Public Health smoking cessation and weight reduction management services prior to surgery. Patient engagement with these preventive services, where commissioned, may influence the immediate outcome of surgery. 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. Page 5 of 100

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, there always remains the option of an application to demonstrate clinical exceptionality through IFR. SCOPE The following policies and procedures are within the scope of this policy. Each policy is categorised as either Not routinely commissioned or restricted these are defined as follows: Not routinely commissioned This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Restricted This means CCG will fund the treatment if the patient meets the stated clinical threshold for care. Policy Treatment Category Adenoidectomy Restricted Cosmetic Surgery Abdominoplasty / Apronectomy Not routinely commissioned Cosmetic Surgery Thigh Lift, Buttock Lift and Arm Not routinely commissioned Lift, Excision of Redundant Skin or Fat Cosmetic Surgery Liposuction Not routinely commissioned Cosmetic Surgery Breast Augmentation a) Non breast cancer b) Breast cancer Not routinely commissioned Restricted Cosmetic Surgery Breast Reduction Restricted Cosmetic Surgery Mastopexy (Breast Lift) Not routinely commissioned Cosmetic Surgery Inverted Nipple Correction Not routinely commissioned Cosmetic Surgery Gynaecomastia (Male Breast Not routinely commissioned Reduction) Cosmetic Surgery Labiaplasty Restricted Cosmetic Surgery Vaginoplasty Restricted Cosmetic Surgery Pinnaplasty Not routinely commissioned Cosmetic Surgery Repair of Ear Lobes Restricted Cosmetic Surgery Rhinoplasty, Septoplasty and Restricted Septorhinoplasty Cosmetic Surgery Face Lift or Brow Lift Restricted (Rhytidectomy) Cosmetic Surgery Hair Depilation (Hirsutism) Restricted Cosmetic Surgery Alopecia (Hair Loss) Not routinely commissioned Cosmetic Surgery Removal of Tattoos / Surgical Not routinely commissioned correction of body piercings and correction of respective problems Cosmetic Surgery Removal of Lipomata Restricted Page 6 of 100

7 Policy Treatment Category Cosmetic Surgery Removal of Benign or Congenital Restricted Skin Lesions Cosmetic Surgery Medical and Surgical Treatment of Not routinely commissioned Scars and Keloids Cosmetic Surgery Botulinum Toxin Not routinely commissioned Injection for the Ageing Face Cosmetic Surgery Treatment for Viral Warts Restricted Cosmetic Surgery Thread / Telangiectasis / Reticular Not routinely commissioned Veins Cosmetic Surgery Rhinophyma Not routinely commissioned Cosmetic Surgery Resurfacing Procedures: Not routinely commissioned Dermabrasion, Chemical Peels and Laser Treatment Cosmetic Surgery Other Cosmetic Procedures Not routinely commissioned Cosmetic Surgery Revision of Previous Cosmetic Not routinely commissioned Surgery Procedures Low Back Pain and Radicular Restricted (Sciatic) Pain Botulinum Toxin for Hyperhidrosis Not routinely commissioned Cataracts Restricted Cholecystectomy for Not routinely commissioned Asymptomatic Gallstones Male Circumcision Restricted Dilation and Curettage (D&C) for Not routinely commissioned Menorrhagia Eyelid Surgery (Upper and Lower) - Restricted Blepharoplasty Ganglion Restricted Grommets Restricted Haemorrhoidectomy Restricted Hip Replacement Surgery Restricted Hysterectomy for Heavy Menstrual Restricted Bleeding Hysteroscopy for Menorrhagia Not routinely commissioned Groin Hernia Repair Restricted Knee Replacement Surgery Restricted Penile Implants Not routinely commissioned Tonsillectomy Restricted Trigger Finger Restricted Varicose Veins Restricted Page 7 of 100

8 IMPLEMENTATION Commissioners, GPs, service providers and clinical staff treating registered patients of the CCGs are expected to implement this policy. When procedures are undertaken on the basis of meeting the criteria specified within the policy, this should be clearly documented within the clinical notes. Failure to do so will be considered by the CCGs as lack of compliance. Patients with problems or conditions that might 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 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. GPs, Consultants in secondary care and provider finance departments need to be aware that the CCG will not pay for the procedures listed in this policy unless the patient meets the criteria outlined in this policy. The CCGs recognise there will be exceptional, individual or clinical circumstances when funding for treatments designated as low priority will be appropriate. Where a treatment is either not routinely commissioned, or the patient does not meet the specified clinical criteria, this means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Individual Funding Requests should only be sent to the respective NHS.net account as below. Guidance regarding IFRs and an application form, can be found on the CCGs websites. IFR contact information follows, however please refer to the CCG IFR policy for more information Individual Funding Request Case Manager Floor Two, Kingston House 438 High Street West Bromwich West Midlands B70 9LD Telephone: addresses for Individual Funding Request teams at CCGs (Ctrl+Click required address to send ): Birmingham CrossCity CCG ifr.bcccg@nhs.net Birmingham South Central CCG ifr.bsc@nhs.net Solihull CCG ifr.solihull@nhs.net NHS Sandwell and West Birmingham CCG ifr.swb@nhs.net Page 8 of 100

9 MONITORING AND REVIEW This policy will be subject to continued monitoring using a mix of the following approaches: Prior approval process 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. COPIES OF THIS POLICY Electronic copies of this policy can be found on the websites of the respective CCGs. Alternatively, you may contact the CCG and ask for a copy of the Harmonised Treatment Policies. Page 9 of 100

10 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. BCH Birmingham Children s Hospital NHS Foundation Trust. BCHC Birmingham Community Healthcare NHS Foundation Trust. 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. Page 10 of 100

11 TERM MEANING Gynaecomastia Benign enlargement of the male breast. Haemorrhoidectomy A procedure to cut away haemorrhoids, sometimes called piles. HEFT Heart of England NHS Foundation Trust. Histology The structure of cells or tissue under a microscope. Hyperhidrosis Excess sweating. Hysteroscopy 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). Individual Funding Request (IFR) 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. 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 commissioned (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 Explanation of the reason why. Restricted (a procedure) This means CCG will fund the treatment if the patient meets the stated clinical threshold for care. Page 11 of 100

12 TERM Rhinophyma Rhinoplasty Rhytidectomy Secondary care Stakeholders Symptomatic Tonsillectomy UHB Vaginoplasty MEANING A condition causing development of a large, bulbous, ruddy (red coloured), nose. A procedure to shape the size and/or shape of the nose. A procedure to restore facial appearance or function. These are sometime called face or brow lifts. Services provided by medical specialists, who generally do not have the first contact with a patient e.g. hospital services. 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. Something causing or exhibiting symptoms. A procedure to remove the tonsils. University Hospital Birmingham NHS Foundation Trust. A procedure to reconstruct the vaginal canal. Page 12 of 100

13 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Adenoidectomy Category Restricted ADENOIDECTOMY An adenoidectomy is an operation to remove the adenoids small lumps of tissue at the back of the nose, behind the palate. Adenoids are part of the immune system, which helps fight infection and protects the body from bacteria and viruses. Adenoids are only present in children. They start to grow from birth and are biggest when your child is approximately three to five years old. But by age seven to eight they start to shrink and by the late teens, are barely visible. By adulthood, the adenoids will have disappeared completely. The adenoids disappear because although they may be helpful in young children they are not an essential part of an adult's immune system. Eligibility Criteria: Adenoidectomy will only be funded if Primary and Secondary Care clinicians undertake maximum medical therapy by following the Royal College of Surgeons High Value Care Pathway for Rhinosinusitis (see weblink below), with surgery reserved for recalcitrant cases e.g. cases that have not responded to maximum medical therapy, with a diagnosis confirmed by radiology, after an appropriate trial of treatment. Or Children or adults with sleep disordered breathing/apnoea confirmed with sleep studies undergo procedure in line with recognised management of these conditions. Page 13 of 100

14 This is because nationally there is a more than five-fold variation in procedure rates for sinus surgery per 100,000 population by CCG across England. Guidance: Royal College of Surgeons Commissioning Guide for Rhinosinusitis (2013): The Royal College of Surgeons of England and ENT UK (2013). Commissioning guide: Rhinosinusitis, Available from: This guide has been prepared for commissioners by the Royal College of Surgeons following a review of the latest research evidence. Robb PJ et al (2009), Tonsillectomy and adenoidectomy in children with sleep-related breathing disorders: consensus statement of a UK multidisciplinary working party, Annals of the Royal College of Surgeons of England, 91, Available from: Page 14 of 100

15 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Solihull Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group Policy for Cosmetic Surgery COSMETIC SURGERY Cosmetic surgery is often carried out to change a person s appearance in order to achieve what they perceive to be a more desirable look. Cosmetic surgery/treatments are regarded as procedures of low clinical priority and therefore not routinely commissioned by the CCG Commissioner. 1. CCG Commissioners require clear evidence of clinical effectiveness before NHS resources are invested in the treatment. 2. CCG Commissioner require clear evidence of cost effectiveness before NHS resources are invested in the treatment 3. The cost of the treatment for this patient and others within any anticipated cohort is a relevant factor. 4. CCG Commissioners will consider the extent to which the individual or patient group will gain a benefit from the treatment 5. 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 6. CCG Commissioners will consider all relevant national standards and take into account all proper and authoritative guidance 7. Where a treatment is approved CCG Commissioners will respect patient choice as to where a treatment is delivered. A good summary of Cosmetic Surgery is provided by NHS Choices. and Specific Procedure Referral Criteria Page 15 of 100

16 Category Not routinely commissioned Intervention: Minimum Eligibility Criteria 1. Abdominoplasty/Apronectomy (sometimes called tummy tuck ) Abdominoplasty and apronectomy 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 it be due to surgical or dietary weight loss. Abdominoplasty is not routinely commissioned. 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. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Royal College of Surgeons Abdominplasty Guide Category Not routinely commissioned Intervention Minimum Eligibility Criteria 2. Thigh Lift, Buttock Lift and Arm Lift, Excision of Redundant Skin or Fat Thigh Lift, Buttock Lift and Arm Lift (Brachioplasty), Excision of Redundant Skin or Fat are surgical procedures performed to remove loose skin or excess fat to reshape body contours. As with abdominoplasty / apronectomy theses procedures are not routinely commissioned. This is because purely removal of loose skin or excess fat irrespective of site on body is deemed to be cosmetic and does not meet the principles laid out in this policy. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Page 16 of 100

17 Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Royal College of Surgeons Liposuction Guide Category Not routinely commissioned Intervention Minimum Eligibility Criteria 3. Liposuction Liposuction (also known as liposculpture) is a surgical procedure performed to improve body shape by removing unwanted fat from areas of the body such as abdomen, hips, thighs, calves, ankles, upper arms, chin, neck and back. Liposuction is sometimes done as an adjunct to other surgical procedures, such as cancer procedures. Liposuction is not routinely commissioned. This is because purely removal of unwanted fat from the above areas is deemed to be cosmetic and does not meet the principles laid out in this policy. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Page 17 of 100

18 Category Non-Breast Cancer Patients - Not routinely commissioned Breast Cancer Patients - Restricted Intervention Minimum Eligibility Criteria 4. Breast Augmentation a) For Non-Breast Cancer Patients Breast Augmentation/enlargement involves inserting artificial implants behind the normal breast tissue to improve its size and shape. Breast Augmentation is not routinely commissioned. This is because breast augmentation for non-cancer reasons is deemed to be cosmetic and does not meet the principles laid out in this policy. This means for patients who do not have breast cancer the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. b) For Breast Cancer Patients, this procedure is restricted. NICE recommends that reconstruction of the cancer affected breast may take place after a mastectomy has been undertaken rather than at the same time as the mastectomy. The CCG will fund this treatment if the patient meets the following criteria: Contra-lateral treatment of the unaffected breast following cancer surgery will be commissioned if undertaken as part of the original treatment plan of reconstruction surgery on the cancer affected breast. Separate later/subsequent applications for such contra-lateral surgery would not be routinely commissioned. This means (for breast cancer patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Royal College of Surgeons Breast Augmentation Guide Page 18 of 100

19 NICE CG80 - Early and locally advanced breast cancer: diagnosis and treatment (2009). NICE Quality Standard 12 Breast Cancer (2011) British Association of Plastic Reconstructive and Aesthetic Surgeons Oncoplastic Breast Reconstruction Best Practice Guidelines (2012) Breast Cancer Care Breast Reconstruction Category Non-Breast Cancer Patients - Not routinely commissioned Breast Cancer Patients - Restricted Intervention Policy Statement 5. Breast Reduction Breast Reduction procedures involve removing excess breast tissue to reduce size and improve shape. This procedure is restricted. The CCG will fund this treatment if the patient meets the minimum eligibility criteria below. This is because Breast Reduction places considerable demand on NHS resources (volume of cases and length of surgery). There is published evidence showing that most women seeking breast reduction are not wearing a bra of the correct size and that a well fitted bra can sometimes alleviate the symptoms that are troubling the patient. Recent evidence has shown that not all commercial bra fitters meet the required standards and so commissioners will need to satisfy themselves that a suitable service is available. Patients seeking breast reduction have physical restrictions on their ability to exercise and additional weight in their excess breast tissue (sometimes 3-4 Kg). The goal of medically necessary breast reduction surgery is to relieve symptoms of pain and disability related to excessive breast weight. This means (for patients who do not meet the criteria below) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Page 19 of 100

20 Minimum Eligibility Criteria a) For Non-Breast Cancer Patients. The patient is suffering from functional problems: - Breast size limits physical activity - Back, neck and shoulder pain caused by the weight of breasts - Has regular indentations from bra straps that support heavy, pendulous breasts - Has skin irritation, intertrigo, beneath the breast crease - Breasts hang low and has stretched skin - Nipples rest below the breast crease when breasts are unsupported - Enlarged areolas caused by stretched skin where any possible causes of these conditions have been considered and excluded AND Symptoms are not relieved by physiotherapy and a professionally fitted brassiere has not relieved symptoms AND The patient has a body mass index (BMI) of less than 27kg/m² AND Has a cup size of F+ (excised breast weight of 500 grams and upwards) AND Is 21 years of age or over Patients should have an initial assessment prior to an appointment with a consultant plastic surgeon to ensure that these criteria are met. At, or following, this assessment, there should be access to a trained bra fitter where it is available. b) For Breast Cancer Patients, this procedure is restricted. The CCG will fund this treatment if the patient meets the following criteria: Contra-lateral treatment of the unaffected breast following cancer surgery will be commissioned if undertaken as part of the original treatment plan of reconstruction surgery on the cancer affected breast. Separate later/subsequent applications for such contra-lateral surgery would however be not routinely commissioned. This means (for breast cancer patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Evidence for inclusion and threshold Royal College of Surgeons Commissioning Guide for Breast Reduction (2014). Royal College of Surgeons Breast Reduction Guide Page 20 of 100

21 NICE CG80 - Early and locally advanced breast cancer: diagnosis and treatment (2009). NICE Quality Standard 12 Breast Cancer (2011) British Association of Plastic Reconstructive and Aesthetic Surgeons Oncoplastic Breast Reconstruction Best Practice Guidelines (2012) Breast Cancer Care Breast Reconstruction Category Non-Breast Cancer Patients - Not routinely commissioned Breast Cancer Patients - Restricted Intervention Policy Statement 6. Mastopexy Mastopexy refers to the surgical correction of breasts that sag or droop. This can occur as part of the natural aging process, or pregnancy, lactation and substantial weight loss. a) For Non-Breast Cancer Patients. Mastopexy is not routinely commissioned. This is because the procedure is deemed to be cosmetic and does not meet the principles laid out in this policy. This means for patients who do not have breast cancer the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. b) For Breast Cancer Patients, this procedure is restricted. The CCG will fund this treatment if the patient meets the following criteria: Contra-lateral treatment of the unaffected breast following cancer surgery will be commissioned if undertaken as part of the original treatment plan of reconstruction surgery on the cancer affected breast. Page 21 of 100

22 Separate later/subsequent applications for such contra-lateral surgery would however be not routinely commissioned. This means for breast cancer patients who DO NOT meet the above criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation NICE CG80 - Early and locally advanced breast cancer: diagnosis and treatment (2009). NICE Quality Standard 12 Breast Cancer (2011) British Association of Plastic Reconstructive and Aesthetic Surgeons Oncoplastic Breast Reconstruction Best Practice Guidelines (2012) Breast Cancer Care Breast Reconstruction Category Non-Breast Cancer Patients - Not routinely commissioned Breast Cancer Patients - Restricted Intervention Policy Statement 7. Inverted Nipple Correction This policy explicitly relates to correction of inverted nipples for cosmetic reasons only. a) For Non-Breast Cancer Patients. Inverted Nipple Correction is not routinely commissioned. This is because correction of inverted nipples is deemed to be cosmetic and does not meet the principles laid out in this policy. This means the CCG will only fund the treatment if an Individual Funding Page 22 of 100

23 Request (IFR) application proves exceptional clinical need and that is supported by the CCG. b) For Breast Cancer Patients, this procedure is restricted. The CCG will fund this treatment if the patient meets the following criteria: Contra-lateral treatment of the unaffected breast following cancer surgery will be commissioned if undertaken as part of the original treatment plan of reconstruction surgery on the cancer affected breast. Separate later/subsequent applications for such contra-lateral surgery would however be not routinely commissioned. This means for breast cancer patients who DO NOT meet the above criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Category Not routinely commissioned Intervention Policy Statement 8. Surgery for Gynaecomastia Gynaecomastia is enlargement of the male breast tissue. It is defined as the presence of >2 cm of palpable, firm, subareolar gland and ductal breast tissue. It may occur at any time and there are a number of causes, some physiological and others pathological. Pathological causes involve an imbalance between the activity of androgens and oestrogens - the former is decreased compared with the latter. Cancers are diagnosed in about 1% of cases of gynaecomastia. Where history or physical examination raises suspicion of cancer, urgent referral for further investigation should be made. Surgery for Gynaecomastia to improve appearance alone is not routinely commissioned. This is because surgery for reduction of male breast tissue is deemed to be cosmetic and does not meet the principles laid out in this policy. Specialist referral to determine the underlying cause of gynaecomastia Page 23 of 100

24 does not sit within the scope of this policy. Any referral to determine the cause of gynaecomastia should be made in the usual way. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Category Restricted Intervention 9. Labiaplasty Policy A labiaplasty is a surgical procedure to reduce the size of the labia minora the flaps of skin either side of the vaginal opening. This procedure is restricted. The CCG will fund this treatment if the patient meets the eligibility criteria below. Eligibility criteria This is because there is a lack of research and clinical evidence to determine how effective this procedure is. This means there is no guarantee it will achieve a long-lasting desired effect, and there are shortand long-term risks to consider. Therefore except where the criteria below is met surgery to reduce the size of the labia is deemed to be cosmetic and does not meet the principles laid out in this policy. RCOG key points for clinicians to note are as follows: Fully informed consent is fundamental when offering FGCS, as is the case for all medical treatment. Clinicians who perform FGCS must be aware that they are operating without a clear evidence base. Women should be advised accordingly. Owing to anatomical development during puberty, FGCS should not normally be offered to individuals below 18 years of age. In general, FGCS should not be undertaken within the National Health Service (NHS) unless it is medically indicated. Where repair of the labia is required after trauma Commissioners require specialists to observe the following RCOG recommendations: Even though children aged 16 or over can consent to surgical procedures, FGCS should not normally be carried out on women and girls under 18 years of age, irrespective of consent, because full genital development is not normally achieved before the age of 18. Where FGCS such as labiaplasty is undertaken, patients must be informed about the risks of the procedure and the lack of reliable Page 24 of 100

25 Guidance: evidence concerning its positive effects. In order to be able to demonstrate compliance with the FGM Act and with good medical practice as defined by the GMC for the purposes of revalidation, it is essential that all surgeons who undertake FGCS keep written records of the physical and mental health reasons which, in their view, necessitate the FGCS procedures they carry out. They should also keep patient consent forms and details of the information provided to the woman about the treatment offered and provided. This means (for patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. NHS Choices Guide to Labiaplasty Royal College of Obstetricians and Gynaecologists - Ethical considerations in relation to female genital cosmetic surgery (FGCS), October Category Restricted Intervention Policy 10. Vaginoplasty Vaginoplasty is a reconstructive plastic surgery and cosmetic procedure for the vaginal canal and its mucous membrane, and of vulvo-vaginal structures that might be absent or damaged because of congenital disease (e.g., vaginal hypoplasia) or because of an acquired cause (e.g., childbirth physical trauma, cancer). The term vaginoplasty generally describes any such cosmetic reconstructive and corrective vaginal surgery, and the term neovaginoplasty specifically describes the procedures of either partial or total construction or reconstruction of the vulvo-vaginal complex. Vaginoplasty and genital procedures are restricted. The CCG will fund this treatment if the patient meets the eligibility criteria below. This is because Vaginoplasty is deemed to be cosmetic and does not meet the principles laid out in this policy. Eligibility criteria Congenital (present from birth) absence or significant developmental/endocrine abnormalities of the vaginal canal Where repair of the vaginal canal is required after trauma. RCOG key points for clinicians to note are as follows: Fully informed consent is fundamental when offering FGCS, as is the case for all medical treatment. Page 25 of 100

26 Clinicians who perform FGCS must be aware that they are operating without a clear evidence base. Women should be advised accordingly. Owing to anatomical development during puberty, FGCS should not normally be offered to individuals below 18 years of age. In general, FGCS should not be undertaken within the National Health Service (NHS) unless it is medically indicated. Where repair of the vaginal canal required after trauma Commissioners require specialists to observe the following RCOG recommendations: Even though children aged 16 or over can consent to surgical procedures, FGCS should not normally be carried out on women and girls under 18 years of age, irrespective of consent, because full genital development is not normally achieved before the age of 18. Where FGCS such as labiaplasty is undertaken, patients must be informed about the risks of the procedure and the lack of reliable evidence concerning its positive effects. In order to be able to demonstrate compliance with the FGM Act and with good medical practice as defined by the GMC for the purposes of revalidation, it is essential that all surgeons who undertake FGCS keep written records of the physical and mental health reasons which, in their view, necessitate the FGCS procedures they carry out. They should also keep patient consent forms and details of the information provided to the woman about the treatment offered and provided. This means (for patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Obstetricians and Gynaecologists - Ethical considerations in relation to female genital cosmetic surgery (FGCS), October Category Not routinely commissioned Intervention Policy Statement 11. Pinnaplasty Pinnaplasty is an operation to reshape the ears and make them less prominent. This can be done from the age of approximately 6 years depending on the thickness of the cartilage. This operation can be performed under local anaesthetic for adults but better under general anaesthetic for children. The surgery is performed as a day case. Pinnaplasty is not routinely commissioned. This is because there are no known links to high quality clinical guidelines/decision support tools for Pinnaplasty. Page 26 of 100

27 Guidance: This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Royal College of Surgeons and British Association of Plastic, Reconstructive and Aesthetic Surgeons Pinnaplasty Commissioning Guide (2013) Category Restricted Intervention 12. Elective Repair of Ear Lobes Policy Statement Ear lobe surgery includes: Congenital Deformity - birth deformities of the earlobe surgery include a simple repair of a congenital cleft or with a significant abnormality, cartilage grafts and skin grafts may be required in one or more stages. Split Earlobes - earlobes are often split by heavy earrings gradually enlarging a piercing over many years. On other occasions, when an earring is forcefully pulled the earlobe can split acutely. Repair is usually performed under local anaesthetic, is simple and re-piercing is normally possible within a few weeks. Earlobe Reduction - correction of droopy earlobes is designed to rejuvenates the ear. Facelift Earlobe - the earlobe is pulled down. Earlobe Keloids - Keloids are scars growing in an uncontrolled manner. Elective repair of split ear lobes in adults is not routinely commissioned. This is because repair of split ear lobes is deemed to be cosmetic and does not meet the principles laid out in this policy. Elective repair of split ear lobes in children is restricted for the surgical indications below ONLY and not for cosmetic reasons: Surgical indications are defined as: Congenital deformity Earlobes split acutely. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Page 27 of 100

28 Category Not routinely commissioned Cosmetic Reasons Restricted Other Reasons Intervention Policy Statement 13. Rhinoplasty; Septoplasty and Septorhinoplasty. Rhinoplasty, commonly known as a nose job, is a plastic surgery procedure for correcting and reconstructing the form, restoring the functions, and aesthetically enhancing the nose by resolving nasal trauma (blunt, penetrating, blast), congenital defect, respiratory impediment, or a failed primary rhinoplasty. a) Rhinoplasty; Septoplasty and Septorhinoplasty are not routinely commissioned for cosmetic reasons. Rationale Minimum Eligibility Criteria b) Rhinoplasty; Septoplasty and Septorhinoplasty are restricted for noncosmetic/other reasons. The CCG will fund this treatment if the patient meets the eligibility criteria below. This is because if you have a blocked nose because your nasal bones are crooked or damaged, or the bone and cartilage between your nostrils is deviated (bent) a septoplasty/septorhinoplasty/rhinoplasty can improve how you breathe. The CCG will fund this treatment if the patient meets the following criteria: Documented medical problems caused by obstruction of the nasal airway AND all conservative treatments have been exhausted. OR Correction of complex congenital conditions e.g. Cleft lip and palate For the purposes of this eligibility criteria, a medical problem is defined as a medical problem that continually impairs sleep and/or breathing. This means (for patients who DO NOT meet the above criteria or require the procedure for cosmetic reasons) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Royal College of Surgeons Rhinoplasty Guide Page 28 of 100

29 Category Restricted Intervention Policy Statement 14. Face Lift or Brow Lift (Rhytidectomy) A facelift, technically known as a rhytidectomy, is a type of cosmetic surgery procedure used to give a more youthful facial appearance. There are multiple surgical techniques. It usually involves the removal of excess facial skin, with or without the tightening of underlying tissues, and the redraping of the skin on the patient's face and neck. Facelifts are effectively combined with eyelid surgery (blepharoplasty) and other facial procedures a) Rhytidectomy is not routinely commissioned for cosmetic reasons. b) Rhytidectomy is restricted for non-cosmetic/other reasons. The CCG will fund this treatment if the patient meets the minimum eligibility criteria below. Rationale Minimum Eligibility Criteria This is because there are many changes to the face and brow as a result of ageing that may be considered normal. However there are a number of specific conditions for which these procedures may form part of the treatment to restore appearance and function. Recognised diagnosis of Congenital (present from birth) facial abnormalities OR Facial palsy (congenital or acquired paralysis) OR As part of the treatment of specific conditions affecting the facial skin e.g. cutis laxa, pseudoxanthoma elasticum, neurofibromatosis OR To correct the consequences of trauma OR For significant deformity following corrective surgery. However funding will not be approved to improve previous cosmetic surgery This means for patients who DO NOT meet the above criteria or require the procedure for cosmetic reasons the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Royal College of Surgeons Facelift Guide Page 29 of 100

30 Category Restricted Intervention Policy Statement 15. Hair Depilation (removal) Hair depilation can be used for excess hair (hirsuitism) in a normal distribution pattern, or for abnormally placed hair. It is usually achieved permanently by electrolysis or laser therapy. Hirsutism essentially means that an individual, usually female, grows too much body or facial hair in a male pattern. Although hirsutism sometimes occurs in males, it is more difficult to detect because of the wide range of normal hair growth in men. Hirsutism affects approximately 10% of women in Western societies and is commoner in those of Mediterranean or Middle-Eastern descent. The British Association of Dermatologists advises that there are a range of treatment options: Self-care: shaving, waxing, depilatories (hair removal creams) and bleaching creams; Physical treatments: electrolysis, or Laser and intense pulsed light (IPL) treatments; Medical treatments: Eflornithine cream, or a range of Anti-androgens. Rationale Minimum Eligibility Criteria Hair depilation is restricted. The CCG will fund this treatment if the patient meets the minimum eligibility criteria below. This is because all excess hair removal treatment that does not meet the criteria below is deemed to be cosmetic and does not meet the principles laid out in this policy. The CCG will fund this treatment if the patient meets the following criteria: Has undergone reconstructive surgery leading to abnormally located hair-bearing skin. For example if reconstructive surgery has led to hair growing in places it would not normally do so such as in the mouth a skin graft that has caused visible excess hair growth. OR Is undergoing treatment for pilonidal sinuses to reduce recurrence This means (for patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: British Association of Dermatologists - hirsuitism patient information leaflet Page 30 of 100

31 Category Not routinely commissioned Intervention Policy Statement 16. Alopecia (Hair Loss) Treatment for Alopecia will not be routinely commissioned. This is because 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).3 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 your GP. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: British Association of Dermatologists - Guidelines for the management of alopecia areata (2012) British Association of Dermatologists - alopecia areata patient information leaflet NHS Choices Guide to Hair Loss Treatment Category Not routinely commissioned Intervention Policy Statement 17. Removal of Tattoos/Surgical correction of body piercings and correction of respective problems Tattoo fading involves using a laser to target tattoo ink in the skin. The laser heats the ink particles, so they break up and allow the body to absorb them. The amount of treatment needed varies, depending on the individual tattoo. However, it can take up to 12 sessions to treat a professional tattoo, which usually takes place once every eight weeks. The results can vary, depending on the individual tattoo and the type or colour of ink used. Indian ink tattoos are usually easier to treat, and black Page 31 of 100

32 Guidance: and red inks tend to fade better. Some inks do not respond to treatment at all. Removal of Tattoos/Surgical correction of body piercings and correction of respective problems is not routinely commissioned. This is because surgical treatment for removal of tattoos/surgical correction of body piercings and correction of respective problems is deemed to be cosmetic and does not meet the principles laid out in this policy. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. NHS Choices Guide to Non-surgical cosmetic procedures Category Restricted Intervention Policy Statement 18. Removal of Benign (non-cancerous) or Congenital Skin Lesions Removal of Benign skin lesions in secondary care including: benign pigmented moles; comedones; corns/callous; Milia; molluscum contagiosum; seborrhoeic keratosis; skin tags (including anal tags); spider angioma (naevus); epidermoid/pilar (sebaceous) cysts warts; xanthelasma and neurofibromata are not routinely commissioned for cosmetic reasons. Rationale Minimum Eligibility Criteria The CCG will fund this treatment if the patient meets the minimum eligibility criteria below. This is because all 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 this policy. The CCG will fund this treatment if the patient meets the following criteria. Treatment of Minor Skin Lesions including: Page 32 of 100

33 o o o o Suspected or proven malignancy (cancerous) OR Due to location the lesion is causing functional impairment OR The lesion is causing obstruction of orifice or vision (for guidance on clinical criteria please refer to the Treatment policy for Upper and Lower Eyelid Surgery (Blepharoplasty). The lesion is a cyst and meets the following criteria: o The cyst has been a persistently infected ( persistent is defined as at least three months) AND o The cyst has not responded to anti-biotics over the 3 month period. AND o The cyst is beyond the scope of primary care to remove AND o The cyst is causing a functional impairment For the purposes of the eligibility criteria, functional impairment is classed as a reduction in the ability to carry out an activity of daily living, e.g. the location of the lesion causes reduced movement resulting in interference with sleeping, eating, or walking. This means for patients who either DO NOT meet the above criteria or require treatment for cosmetic reasons the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Evidence for inclusion and threshold NHS Modernisation Agency - Information for commissioners of Plastic Surgery - referrals and guidelines in Plastic Surgery (Action on Plastic Surgery) (2005) bee1-413a-8da1-8098b0495cf6 Category Restricted Intervention Policy Statement Rationale Minimum Eligibility Criteria 19. Removal of Lipomata Lipomata are fat deposits underneath the skin. They are usually removed on cosmetic grounds, although patients with multiple subcutaneous lipomata may need a biopsy to exclude neurofibromatosis. Removal of Lipomata in secondary care is restricted. The CCG will fund this treatment if the patient meets the minimum eligibility criteria below. This is because all removal of Lipomata that does not meet the criteria below is deemed to be cosmetic and does not meet the principles laid out in this policy. The CCG will fund this treatment if the patient meets the following criteria: suspected or proven malignancy (cancerous) OR significant functional impairment caused by the lipoma OR Page 33 of 100

34 to provide histological evidence in conditions where there are multiple subcutaneous lesions OR the lipoma is on the face (including pinna) or the neck and it has become infected or is causing functional impairment. Lipomas on other areas of the body should be referred back to primary care as agreed locally. For the purposes of the eligibility criteria, functional impairment is classed as a reduction in the ability to carry out an activity of daily living, e.g. the location of the lesion causes reduced movement resulting in interference with sleeping, eating, or walking. This means for patients who DO NOT meet the above criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Evidence for inclusion and threshold NHS Modernisation Agency - Information for commissioners of Plastic Surgery - referrals and guidelines in Plastic Surgery (Action on Plastic Surgery) (2005) bee1-413a-8da1-8098b0495cf6 Category Restricted Intervention: Policy Statement 20. Medical and Surgical treatment of Scars and Keloids The different types of scars include: Flat, pale scars these are the most common type of scar and are due to the body's natural healing process. Initially, they may be red or dark and raised after the wound has healed, but will become paler and flatter naturally over time. This can take up to two years. Hypertrophic scars red, raised scars that form along a wound and can remain this way for a number of years. Keloid scars these are caused by an excess of scar tissue produced at the site of the wound, where the scar grows beyond the boundaries of the original wound, even after it has healed. Pitted (atrophic or "ice-pick") scars these have a sunken appearance. Contracture scars these are caused by the skin shrinking and tightening, usually after a burn, which can restrict movement. Treating scars Depending on the type and age of a scar, a variety of different treatments may help make them less visible and improve their appearance. Scars are unlikely to disappear completely, although most will gradually fade over time. If scarring is unsightly, uncomfortable or restrictive, treatment options may include: Page 34 of 100

35 silicone gel sheets pressure dressings corticosteroid injections cosmetic camouflage (make-up) surgery It is often the case that a combination of treatments can be used. Refashioning or removal of scars/treatment and keloids are restricted. The CCG will fund this treatment if the patient meets the minimum eligibility criteria below. This is because Medical and Surgical treatment of Scars and Keloids that does not meet the criteria below is deemed to be cosmetic and does not meet the principles laid out in this policy. Minimum Eligibility Criteria The CCG will fund this treatment if the patient meets the following criteria: For severe post burn cases or severe traumatic scarring or severe postsurgical scarring OR Revision surgery for scars following complications of surgery, keloid formation or other hypertrophic scar formation will only be commissioned where there is significant functional deformity or to restore normal function This means for patients who DO NOT meet the above criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Category Not routinely commissioned Intervention Policy Statement 21. 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, your 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. Page 35 of 100

36 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. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. NHS Choices Guide to Non-surgical cosmetic procedures Category Restricted Intervention Policy Statement 22. Treatment for Viral Warts Warts are small lumps that often develop on the skin of the hands and feet. Warts vary in appearance and may develop singly or in clusters. Some are more likely to affect particular areas of the body. For example, verrucas are warts that usually develop on the soles of the feet. Warts are non-cancerous, but can resemble certain cancers. Treatment for Viral Warts is restricted to the minimum eligibility criteria below. The CCG will fund this treatment if the patient meets the following criteria below. This is because most plantar warts can be managed with over-the counter topical treatments or by treatments prescribed by your general practitioner. Treatment for Viral Warts that does not meet the criteria below is deemed to be cosmetic and does not meet the principles laid out in this policy. Minimum Eligibility Criteria The CCG will fund this treatment if the patient meets the following criteria. ano-genital warts that have failed treatment within primary care setting or Genito-Urinary Medicine (GUM) clinic. This means for patients who DO NOT meet the above criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: British Association of Dermatologists - Plantar Warts patient information leaflet Page 36 of 100

37 NHS Choices Guide to Non-surgical cosmetic procedures Category Not routinely commissioned Intervention Policy Statement 23. Thread/ Telangiectasis/ Reticular veins (Spider Angiomas) A spider angioma is an enlarged little artery (resembling the body of a spider), from which smaller blood vessels are filled (resembling the spider s legs). It has also been called several other names, for example naevus araneus, vascular spider, arterial spider, spider telangiectasia and spider naevus/nevus. The cause of spider angiomas is not known. The vast majority affect healthy people, and most only have one spider angioma or a just a few. Spider angiomas may appear in certain conditions with increased levels of oestrogen hormones such as in pregnancy or when taking the oral contraceptive pill. They may occasionally be linked to liver or thyroid disease. Spider angiomas can develop at any age, but are more common in children. Treatment for Thread Veins/Telangiectasia will not be routinely commissioned. This is because: In children and some adults, spider angiomas may go away on their own, which can take several years. Treatment is usually not necessary. If spider angiomas are related to increased oestrogen hormones and the levels then go back to normal (after a pregnancy or on stopping an oral contraceptive pill), the spider angiomas may go away within about nine months. A spider angioma can also completely disappear after treatment, but sometimes repeated treatments may be required. The problem may come back a few months later after treatment. Treatment for removal of Spider Angioma involves the central artery being treated with an electric current ( electrodissication ), causing it to dry up. A vascular laser such as the pulsed dye laser or KTP laser can target the blood in the central small artery, causing it to shrink. This treatment is deemed to be cosmetic and does not meet the principles laid out in this policy. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Page 37 of 100

38 British Association of Dermatologists - Spider Angioma patient information leaflet Category Not routinely commissioned Intervention Policy Statement 24. Rhinophyma (bulbous, red nose) Rhinophyma is a swelling of the nose. If the condition progresses, the nose becomes redder, swollen at the end and gains a bumpy surface which changes its shape. This swelling is because there is formation of scar-like tissue and the sebaceous glands (which produce oil on the skin) get bigger. Much more rarely, swellings can arise on other parts of their face such as the ears and chin. The condition is mainly seen in those who have rosacea, a rash that can affect the cheeks, forehead and nose (see rosacea leaflet for further information). Rhinophyma usually only develops in rosacea which has been active for many years. However, although rosacea affects woman more than men, rhinophyma is seen mainly in fair-skinned men aged 50 to 70 years. Surgical treatment of Rhinophyma is not routinely commissioned. This is because there is no cure for rhinophyma, although some treatments may control it. These treatments are deemed to be cosmetic and does not meet the principles laid out in this policy. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: British Association of Dermatologists - Rhinophyma patient information leaflet Page 38 of 100

39 Category Not routinely commissioned Intervention Policy Statement 25. Resurfacing Procedures: Dermabrasion, Chemical Peels and Laser Treatment Resurfacing procedures including dermabrasion, chemical peels and laser treatment are not routinely commissioned. 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. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: British Association of Dermatologists - Rhinophyma patient information leaflet Category Not routinely commissioned Intervention Policy Statement 26. Other Cosmetic Procedures Cosmetic Procedures are not routinely commissioned. The Royal College of Surgeons Categorisation of Cosmetic Surgery includes the following procedures: Cosmetic breast surgery Cosmetic surgery of the nipple areolar complex Augmentation mammoplasty Autologous fat transfer to breast for symmetrisation / augmentation Breast symmetrisation Correction of gynaecomastia Mastopexy Reduction mammoplasty Cosmetic nasal surgery Rhinoplasty Cosmetic surgery of the periorbital region Brow lift Midface lift Upper lid blepharoplasty Lower lid blepharoplasty Cosmetic surgery of the ear Page 39 of 100

40 Otoplasty Cosmetic facial contouring surgery Alloplastic augmentation of the facial skeleton Bone grafting of the facial skeleton Free fat grafting to the face Genioplasty: sliding, reduction, lengthening and symmetrising Cosmetic surgery of the face Cosmetic facial contouring Brow lift Rhytidectomy Platysmaplasty Cosmetic surgery of the face/nose/periorbital region/ears Alloplastic augmentation of the facial skeleton Alloplastic facial augmentation Autologous fat transfer Blepharoplasty Bone grafting of the facial skeleton Brow Lift Rhytidectomy Facial contouring surgery Free fat grafting to the face Genioplasty Midface lift Otoplasty Platysmaplasty Reconstructive facial recontouring or remodelling Rhinoplasty Cosmetic body contouring surgery Abdominoplasty Cosmetic surgery of the hand Autologous fat transfer Body lift Brachioplasty Gluteal augmentation Calf augmentation Liposuction Thigh lift Massive weight loss surgery (MWL) - Supplementary certificate in body contouring following massive weight loss Post bariatric surgery/mwl abdominoplasty Post bariatric surgery/mwl brachioplasty Post bariatric surgery/mwl autologous fat transfer Post bariatric surgery/mwl body lift Post bariatric surgery/mwl liposuction Post bariatric surgery/mwl thigh lift Page 40 of 100

41 This is because Other Cosmetic Procedures not specified in the Cosmetic Surgery policy but detailed in the Royal College of Surgeons Categorisation of Cosmetic Surgery is deemed to be cosmetic and does not meet the principles laid out in this policy. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation NHS Choices Ear Reshaping Category Not routinely commissioned Intervention Policy Statement 27. Revision of Previous Cosmetic Surgery Procedures Revision surgery following previous NHS cosmetic surgery is not routinely commissioned. This is because the financial risk of revision surgery lies with the provider. It is also important to note that revision of plastic surgery procedures originally performed in the private sector will not be funded. Referring clinicians should re-refer to the practitioner who carried out the original treatment. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance: Royal College of Surgeons - Cosmetic Surgery Categorisation Page 41 of 100

42 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Low Back Pain and Radicular Pain Category Restricted (based on national recommended practice) 1.Low Back Pain and Radicular Pain Patient Information (pages 1-3) This information has been written by Keele University, Research Institute for Primary Care and Health Sciences to accompany the STarT Back Screening Tool which enables your GP to classify back pain patients according to their risk of on-going disability and then to ensure patients receive the appropriate treatment for them. 1.1 Introduction About 8 out of 10 people will experience low back pain and we know that it is one of the most common reasons why middle-aged people visit their GP. Although it is common, it is very rare that back pain is caused by a serious disease. Most cases of back pain get better over a period of weeks. The best advice is to keep active, do normal activities and return to work as soon as you can. This may be supported by a local employers Return To Work policy and local occupational health arrangements where they exist. Heart of England NHS Foundation Trust has produced a short video about how you can manage your back pain: 1.2Causes of back pain Non-specific - the cause in the vast majority of people It is often impossible to find a precise cause for low back pain. Less than 1 in 100 people have a serious problem. It can be caused by an injury or sprain, but most of the time it isn't and may be due to poor posture, lack of exercise or stiffness. You may have heard your doctor, physiotherapist or nurse describing your back pain as 'non-specific' or 'simple' back pain. This means that after your examination, the clinician is not concerned that you have a serious medical condition. This is the type of back pain that is likely to get better over the next few weeks as you gradually return to normal activities and work. Page 42 of 100

43 1.2.2 Sciatica This is far less common and affects less than 1 in 20 people. It is most often caused by pressure or irritation of nerves as they come out of the lower back. The symptoms include pain, numbness and tingling that spread down the leg, sometimes reaching the calf or foot. Most people do recover from sciatica over time but often it takes longer than with non-specific back pain Rare causes In less than 1 in 100 cases back pain has a more serious cause. These include infection, fracture, tumour or inflammation. 1.3 When to seek medical help Severe pain that doesn't improve. If you have had a fall that caused your back pain to start. If you have had cancer in the past. If you are taking steroid tablets or have osteoporosis. If you have a fever or are generally unwell. If you have difficulty or changes in passing urine or opening your bowels. Numbness around your genitals or back passage. Weakness of the leg(s) that is getting worse. 1.4 Natural history About 8 out of 10 people will get back pain at some point in their lives; it often re-occurs but will settle for most people in a matter of weeks. 1.5 Investigations The doctor, physiotherapist or nurse will be able to diagnose your problem by taking a full history of your difficulties and an examination of your back and legs. Investigations such as X-rays and scans are rarely needed as they don't help the clinicians to diagnose your problem and they don't provide a cure. X-rays involve a dose of radiation so need to be used responsibly. 1.6 Painkillers It is advisable to take painkillers; this can be guided by your GP or pharmacist. It is best to take them regularly rather than taking them now and again. This will allow you to continue with day-to-day activities more comfortably. 1.7 Exercise A gradual return to exercise and general activity is very helpful for your recovery. Regular exercises may also help to prevent the back pain from returning. Try to set a new goal everyday - for example, a walk around the house on one day and a walk to the shops the next day. 1.8 Activity Try not to rest in bed; pace your activities. Pay attention to your posture and your back position when lifting. Try not to slouch when sitting. Try to maintain an 'S' shaped spine. This is the least stressful position for the spine. You are more likely to stay pain-free in the future if you keep active rather than resting a lot. Page 43 of 100

44 1.9 Sleep You may want to consider taking a painkiller just before bedtime. Some people say that a small pillow in between their knees helps them to sleep Pain Pain doesn't equal harm. Most people recover quickly and have no lasting problems. Sometimes people do become worried or depressed. Please see your GP if you think this is a problem for you Work If you have a job, try to return to work as soon as possible. It is safe to return to work before you are pain-free. Talk to your GP and your employer about this at an early stage to assist your speedy return to work. The longer you stay off work, the more likely you are never to return. Research tells us that you are more likely to improve quickly by getting moving and getting back to work as soon as possible. Page 44 of 100

45 2. From National Low Back and Radicular Pain Pathway 2017 (Including Implementation of NICE Guidance NG59) The Birmingham and Solihull Spinal Programme Board has endorsed the in and out of hospital elements of the pathway charts below. Pathfinder Back Pain Pathway Chart Page 45 of 100

46 Page 46 of 100

47 Policy Statement of recommended clinical practice based on NICE CG59 The recommendations below reflect the patient journey with low back pain or radicular pain starting with the patient presenting in the Primary Care or Community Setting. If the recommended interventions at this stage are not successful then the patient will progress to the next level of Community or Secondary Care Non-Surgical Interventions. Finally if recommended interventions at this stage are not successful then Secondary Care Surgical Interventions may be necessary. 3. Primary Care or Community Setting 3.1 STarT Back Risk assessment undertaken using STarT Back 9 point questionnaire ( Reassurance, encouragement to stay active, early managed return to work (per above patient information). Depending on the results of the STarT Back questionnaire the following next steps are recommended: Page 47 of 100

48 3.2 Imaging advice to GP Do not routinely offer imaging such as MRI in a non-specialist (primary care) setting for people with low back pain with or without sciatica. Explain to people with low back pain with or without sciatica that if they are being referred for Specialist Triage Practitioner (STP) opinion, they may not need imaging but that if the Physiotherapist STP assesses that imaging is necessary they will make a direct access request to hospital imaging services and consider the imaging results in that specialist setting. 3.3 Options Not Recommended Orthotics: Belts or corsets; foot orthotics or rocker sole shoes Acupuncture Electrotherapies: ultrasound Electrotherapies. Percutaneous electrical nerve simulation (PENS) Electrotherapies. Transcutaneous electrical nerve simulation (TENS) Electrotherapies. Interferential therapy Pharmacological: Do not offer Paracetamol alone for managing low back pain Do not routinely offer opioids for managing acute low back pain, unless an NSAID is contraindicated, not tolerated or has been ineffective Do not offer opioids for managing chronic low back pain Do not offer selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors or tricyclic antidepressants for managing low back pain Do not offer anticonvulsants for managing low back pain. 3.4 Options to Consider Self-Management: information on the nature of low back pain and sciatica Self-Management: encouragement to continue with normal activities Self-Management: Promote and facilitate return to work or normal activities of daily living More complex and intensive support for exercise programmes with or without manual therapy or using a psychological approach: for people with low back pain with or without sciatica at higher risk of a poor outcome Consider a group exercise programme (biomechanical, aerobic, mind body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) as part of a wider exercise package with or without psychological therapies using a cognitive behavioural approach Combined physical and psychological programmes (CPPP) incorporating a cognitive behavioural approach (preferably in a group context that takes into account a person's specific needs and capabilities), for people with persistent low back pain or sciatica: when significant psychosocial obstacles to recovery (for example, avoiding normal activities based on inappropriate beliefs about their condition) or when previous treatments have not been effective. Page 48 of 100

49 3.4.8 Pharmacological: For sciatica, see NICE's guideline [CG173] - Neuropathic pain in adults: pharmacological management in non-specialist settings, February For low back pain consider oral non-steroidal anti-inflammatory drugs (NSAIDs) for managing low back pain, taking into account potential differences in gastrointestinal, liver and cardio-renal toxicity, and the person's risk factors, including age Consider weak opioids (with or without paracetamol) for managing acute low back pain only if an NSAID is contraindicated, not tolerated or has been ineffective. 4 Community or Secondary Care Non-Surgical Interventions 4.1 Options Not Recommended Spinal injections e.g. Generally facet Joint Injections, nerve root block (an injection of local anaesthetic (numbing medicine) and steroid injected under X-ray guidance into the area where the nerve exits the spinal column) and epidurals, for managing low back pain. There may however be a relatively small group of patients who could benefit from nerve root block injection. Suggested local selection criteria could include: Patient over 50 years old Localised low back pain without radiation. Pain specifically aggravated in standing and walking and relatively better when sitting. Pain provoked on assessing active lumbar extension +/- side flexion to either side with flexion more comfortable Imaging showing relatively more degeneration with at one or two levels +/- facet joint cysts and effusions Imaging for people with low back pain with specific facet join pain as a prerequisite for radiofrequency denervation Epidural injections for neurogenic claudication in people who have central spinal canal stenosis. There are however, in practice, a select group of more elderly patients that are unfit/unable to tolerate all other modes of treatment, for whom this is their only option. 4.2 Options to Consider Assessment for radiofrequency denervation for people with chronic low back pain if: o non-surgical treatment has not worked for them and The patient reports more than 75% reduction in low back within the first 2 weeks following medial branch block injection The patient meets the criteria for facet joint mediated pain as already listed, namely: Patient over 50 years old Localised low back pain without radiation. Pain specifically aggravated in standing and walking and relatively better when sitting. Pain provoked on assessing active lumbar extension +/- side flexion to either side with flexion more comfortable Imaging showing relatively more degeneration with at one or two levels +/- facet joint cysts and effusions. They have exhausted other, less destructive interventions such as physical Page 49 of 100

50 o o rehabilitation and/or pharmacology if appropriate and chosen by the patient; and; the main source of pain is thought to come from structures supplied by the medial branch nerve, namely the facet joint, and; they have moderate or severe levels of localised back pain (rated as 5 or more on a visual analogue scale, or equivalent) at the time of referral. In practice one can use a NRS (numerical rating scale) alongside a validated outcome measure such as Oswestry Disability Index) to assess levels of disability. The patient s own comments about limitations to daily living may also be relevant to consider Radiofrequency denervation: only in people with chronic low back pain after a positive response to a diagnostic medial branch block. Definitions: Acute pain: generally lasting less than 3 months; Sub acute pain: 3-6 months; Chronic pain: over 6 months Epidural injections of local anaesthetic and steroid and nerve root blocks in people with acute and severe sciatica for up to 6 months. Note: There will be some patients who will offered this treatment modality at a later than 6 month for reasons including: o disc shrinking back but leg pain continues, o patient does not want surgery, o patient not fit for surgery, o unclear how much back pain restricts function relative to leg pain). 5.2 Options Not Recommended Spinal fusion for people with low back pain unless as part of a randomised controlled trial Disc replacement in people with low back pain. 5.3 Options to Consider Spinal decompression for people with sciatica when non-surgical treatment has not improved pain or function and their radiological findings are consistent with sciatic symptoms. Treatment options each pathway stage outside of the above recommended practice will only be funded if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG Page 50 of 100

51 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Botulinum Toxin for Hyperhidrosis Category Not routinely commissioned BOTULINUM TOXIN FOR HYPERHIDROSIS Normal sweating helps to keep the body temperature steady in hot weather, during a high temperature (fever) or during exercise. Excessive sweating (hyperhidrosis) means sweating more than normal. Hyperhidrosis can be challenging to treat and it may take a while to find the best treatment for you. Less invasive treatments will usually be recommended first, including: Lifestyle changes Stronger antiperspirants Prescribing Anticholinergics Referral to a dermatologist (see British Association of Dermatologists patient information weblink below) 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. Therefore this document summarises the commissioning status of Botulinum Toxin A for specified medical conditions. Botulinum Toxin (type A) for hyperhidrosis is not routinely commissioned. This is because Botulinum toxin is only licensed for underarm sweating and not for large areas. The skin can be numbed with an anaesthetic cream or injection, but this is often not needed as underarm skin is not very sensitive. Botulinum toxin is not commonly used in the palms and soles because it can cause temporary weakness of hand and foot muscles and is painful. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application Page 51 of 100

52 proves exceptional clinical need and that is supported by the CCG. Guidance: British Association of Dermatologists - Hyperhidrosis patient information leaflet NHS Choices Guide to Hyperhidrosis and Page 52 of 100

53 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Cataracts Category Restricted CATARACTS A cataract exists when the lens of an eye becomes cloudy and may affect vision. Cataracts most commonly occur in older people and develop gradually. Cataracts can usually be treated with a routine day case operation where the cloudy lens is removed and is replaced with an artificial plastic lens (an Intraocular Implant). The National Institute for Health and Care Excellence published new guidance in 2017 which stated that access to cataract surgery should not be restricted on the basis of visual acuity. It is good practice that referrals for assessment for cataract surgery are made based on the pathway laid out in NICE Guidance 77. At referral for cataract surgery, give people information about: cataracts: o o o what cataracts are how they can affect vision how they can affect quality of life cataract surgery: o what it involves and how long it takes Page 53 of 100

54 o o o o o possible risks and benefits what support might be needed after surgery likely recovery time likely long-term outcomes, including the possibility that people might need spectacles for some tasks how vision and quality of life may be affected without surgery. Base the decision to refer a person with a cataract for surgery on a discussion with them (and their family members or carers, as appropriate) that includes: how the cataract affects the person's vision and quality of life whether 1 or both eyes are affected what cataract surgery involves, including possible risks and benefits how the person's quality of life may be affected if they choose not to have cataract surgery whether the person wants to have cataract surgery Once a referral has been made to secondary care, funding for cataract surgery will be supported if the patient meets the following eligibility criteria: Page 54 of 100

55 Eligibility criteria Cataract eye surgery is restricted. The CCG will fund this treatment if the patient meets ONE of the following eligibility criteria for each eye: The patient s lifestyle is affected by disabling visual symptoms attributable to cataract such as: - Difficulty carrying out everyday tasks such as recognising faces, watching TV, cooking, playing sport/cards etc. - Reduced mobility, unable to drive or experiencing difficulty with steps or uneven ground. - Ability to work, give care or live independently is affected. The CCG will also fund cataract surgery if the patient has ONE of the following diagnoses which requires cataract surgery with OR without the above mentioned visual symptoms: Monitoring posterior segment disease e.g. diabetic retinopathy Correcting anisometropia Patient with Glaucoma who require cataracts surgery to control intraocular pressure. Patients with single sight (monocular vision) The indications for cataract surgery in patients with monocular vision and those with severe reduction in one eye e.g. dense amblyopia, are the same as for patients with binocular vision according to The Royal College of Ophthalmologists 2015 Cataract Surgery guidance This means for patients who DO NOT meet the specified criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Page 55 of 100

56 Royal College of Ophthalmologist Recommended Pathway (Cataract Surgery) Guidance National Institute for Health and Care Excellence (2017) NICE Guidance 77 Cataracts in adults: management Royal College of Ophthalmology - Commissioning Guide: Cataract Surgery (2015) Final-February-2015.pdf Royal College of Ophthalmologists Cataract Surgery Guidelines (2010) : Guidelines-2010-SEPTEMBER-2010.pdf Health Information and Quality Authority (2013) Health Technology Assessment of Scheduled Surgical Procedures: Cataract Surgery DVLA Driving Standards These describe the minimum standards of vision for driving. Page 56 of 100

57 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Cholecystectomy for Asymptomatic Gallstones Category Not routinely commissioned CHOLECYSTECTOMY FOR ASYMPTOMATIC GALLSTONES Gallstones are small stones usually made of cholesterol that form in the gallbladder. In most cases they do not cause any symptoms i.e. they are asymptomatic. Cholecystectomy is the surgical removal of the gallbladder, this is not usually indicated in patients with asymptomatic gallstones. Note: Patients with suspected gallbladder carcinoma or severe complications should be referred/treated immediately, without delay. Cholecystectomy for Asymptomatic Gallstones is not routinely commissioned. This is because the majority of people with gallbladder stones remain asymptomatic (without symptom) and require no treatment. If you do not have any symptoms, a policy of 'active monitoring' is often recommended. This means you won't receive immediate treatment, but you should let your GP know if you notice any symptoms. As a general rule, the longer you go without symptoms, the less likely it is that your condition will get worse. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. For patients with symptoms follow the Royal College of Surgeons guidance detailed below. Page 57 of 100

58 High value care pathway for gallstone disease Management RCS Commissioning Guide: Gallstone Disease Patients with an incidental finding of stones in an otherwise normal gallbladder require no further investigation or referral. Most patients with symptomatic gallstones present with a self-limiting attack of pain that lasts for hours only. This can often be controlled successfully in primary care with appropriate analgesia, avoiding the requirement for emergency admission. When pain cannot be managed or if the patient is otherwise unwell (eg sepsis), he or she should be referred to hospital as an emergency. Further episodes of biliary pain can be prevented in around 30% of patients by adopting a low fat diet. Fat in the stomach releases cholecystokinin, which precipitates (brings about) gallbladder contraction and might result in biliary pain. Patients with suspected acute cholecystitis, cholangitis or acute pancreatitis should be referred to hospital as an emergency. There is no evidence to support the use of hyoscine or proton pump inhibitors in the management of gallbladder symptoms. Antibiotics should be reserved for patients with signs of sepsis. There is no evidence of benefit from the use of non-surgical treatments in the definitive management of gallbladder stones (e.g. gallstone dissolution therapies, ursodeoxycholic acid or extracorporeal lithotripsy). Best practice referral guidelines Epigastric or right upper quadrant pain, frequently radiating to the back, lasting for several minutes to hours (often occurring at night) suggests symptomatic gallstones. These patients should have liver function tests checked and be referred for ultrasonography. Confirmation of symptomatic gallstones should result in a discussion of the merits of a referral to a surgical service regularly performing cholecystectomies. Following treatment for CBD stones with endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, removal of the gallbladder should be considered in all patients. However, in patients with significant co-morbidities (other risk factors alongside the primary problem), the risks of surgery may outweigh the benefits Treatment is available for patients that are at high risk of the following: Patients with diabetes mellitus/transplant recipient patients/patients with cirrhosis who have been managed conservatively and subsequently develop symptoms Where there is clear evidence of patients being at risk of gallbladder carcinoma Confirmed episode of Gallstone induced pancreatitis Confirmed episode of Cholecystiti Episode of obstructive jaundice caused by biliary calculi. Guidance NICE CG Gallstone disease: diagnosis and initial management (2014) Royal College of Surgeons - Commissioning Guide: Gallstone disease and Best Practice Referral Page 58 of 100

59 Guideline (2013). NHS Choices Gallstones Page 59 of 100

60 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Male Circumcision Category Restricted MALE CIRCUMCISION Male circumcision is an operation to remove the foreskin (the skin covering the top of the penis). It is mostly done in babies and young children but can be done at any age. It is an effective procedure and confers benefit for a range of medical indications. Sometimes it is requested on cultural, social and religious reasons and is a common practice in the Jewish and Islamic faiths, and is also practised by many African communities as a tribal or ethnic tradition. This policy refers only to male circumcision for medical reasons, which is restricted. The CCG will fund this treatment if the patient meets the eligibility criteria below. Note: Female circumcision has no medical benefits and is illegal under the Female Genital Mutilation Act (2003). Eligibility Criteria The CCG will fund this treatment if the patient meets the following criteria. Circumcision will be funded in the following medical circumstances: Pathological phimosis - a condition where the foreskin gets trapped under the tip of the penis 3 documented episodes of balanoposthitis (inflammation of the head of the penis). This can lead to Phimosis is a condition where the foreskin is too tight to be pulled back over the head of the penis (glans). Both can be indications for medical circumcision. Relative indications for circumcision or other foreskin surgery include the following: - Prevention of urinary tract infection in patients with an abnormal urinary tract - Recurrent paraphimosis - Trauma (e.g. zipper injury) - Tight foreskin causing pain on arousal/ interfering with sexual function Page 60 of 100

61 Guidance - Congenital abnormalities This is because if the patient does not meets the medical indications above non-medical circumcisions do not confer any health gain but do carry health risk. This means for patients who DO NOT meet the specified criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. The Royal College of Surgeons of England and British Associations of Urological Surgeons/ British Associations of Paediatric Surgeons/British Associations of Paediatric Urologists Draft Commissioning guide: Foreskin conditions (2016). NHS Choices Circumcision Page 61 of 100

62 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Dilation and Curettage (D&C) for Menorrhagia Category Not routinely commissioned DILATION AND CURETTAGE (D&C) FOR MENORRHAGIA Heavy periods, also called menorrhagia, is when a woman loses an excessive amount of blood during consecutive periods. Menorrhagia can occur by itself or in combination with other symptoms, such as menstrual pain (dysmenorrhoea). Heavy bleeding does not necessarily mean there is anything seriously wrong, but it can affect a woman physically, emotionally and socially, and can cause disruption to everyday life. Dilation and Curettage for Menorrhagia has been the traditional technique for obtaining samples of endometrium for pathological examination. However, 'blind' dilatation and curettage (D&C) has been shown to miss significant amounts of pathology. Dilatation and curettage for Menorrhagia is not routinely commissioned. This is because NICE Clinical Guideline 44 recommends that: - Ultrasound is the first-line diagnostic tool for identifying structural abnormalities. - Dilatation and curettage should not be used as a diagnostic tool. - Dilatation and curettage should not be used as a therapeutic treatment. This means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Page 62 of 100

63 NICE - Clinical guideline: Heavy menstrual bleeding CG44 (2007). NHS Choices - Heavy periods (menorrhagia) Page 63 of 100

64 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Eyelid Surgery (Upper and Lower) Category Restricted EYELID SURGERY (BLEPHAROPLASTY) Blepharoplasty is a surgical procedure performed to correct puffy bags below the eyes and droopy upper eyelids. It can improve appearance and widen the field of peripheral vision. This procedure will be commissioned by the NHS to correct functional impairment. As detailed in the Cosmetic Surgery Policy, eyelid surgery will not be routinely commissioned for purely for cosmetic reasons. This policy refers to upper and lower eyelid surgery which is restricted. The CCG will fund this treatment if the patient meets the eligibility criteria below. Note: The following eyelid surgery procedures will not be funded: 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 lid lumps This is because all 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). Page 64 of 100

65 This means (for patients who either DO NOT meet the eligibility criteria below or require treatment for cosmetic reasons) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. 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. Eligibility criteria This procedure is restricted. The CCG will fund this treatment if the patient meets the following eligibility criteria: Demonstrated by: Impairment of vision in the relaxed, non-compensated state as determined by the Visual field test reducing visual field to 120 laterally and/or more than 40 reduction vertically OR Severe 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 inflammatory material under local anaesthetic. This criterion applies to ptosis as well as brow lift cases. This is because all eyelid surgery procedures other than for the eligibility criteria are deemed to be cosmetic and do not meet the principles laid out in the Cosmetic Surgery. For the purposes of this clinical eligibility criteria, conservative therapy of a chalazion is defined as the following: Most cysts disappear with time but can take weeks and sometimes many months, to go. They are normally harmless and can be safely left to get better with time in most cases. Warm compresses might speed up the disappearance of the cyst. Use clean cotton wool or a clean flannel soaked in very warm water (be sure it s not hot enough to burn). Squeeze out excess water and place the flannel or cotton wool on the patient s closed eyelids over the cyst for two minutes at a time twice daily. Occasionally, the doctor will prescribe a short course of antibiotic ointment or drops to help any irritation and, if there is infection spreading from the cyst, will prescribe antibiotics by mouth. However, medication does not cause the cysts to disappear. This means (for patients who DO NOT meet the specified criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Page 65 of 100

66 Surgery on the Lower eyelid (Lower lid blepharoplasty) Eligibility criteria The CCG will fund this treatment if the patient meets the following eligibility criteria: ectropion (eyelid turned outwards from the eyeball), OR entropion (eyelid folds into the eyeball) or for the removal of lesions of the eyelid skin or lid margin. 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 inflammatory material under local anaesthetic. For the purposes of this clinical eligibility criteria, conservative therapy of a chalazion is defined as the following: Most cysts disappear with time but can take weeks and sometimes many months, to go. They are normally harmless and can be safely left to get better with time in most cases. Warm compresses might speed up the disappearance of the cyst. Use clean cotton wool or a clean flannel soaked in very warm water (be sure it s not hot enough to burn). Squeeze out excess water and place the flannel or cotton wool on the patient s closed eyelids over the cyst for two minutes at a time twice daily. Occasionally, the doctor will prescribe a short course of antibiotic ointment or drops to help any irritation and, if there is infection spreading from the cyst, will prescribe antibiotics by mouth. However, medication does not cause the cysts to disappear. Note: Excessive skin in the lower lid may cause eyebags but does not affect function of the eyelid or vision and therefore does not need correction. Blepharoplasty type procedures may form part of the treatment of pathological conditions of the lid or overlying skin and not for cosmetic reasons. This is because all eyelid surgery procedures are deemed to be cosmetic and do not meet the principles laid out in the Cosmetic Surgery. This means (for patients who DO NOT meet the specified criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance Royal College of Surgeons Blepharoplasty Guide Commissioning Guide - Referrals and Guidelines in Plastic Surgery (Modernisation Agency 2005) Page 66 of 100

67 NHS Choices Cosmetic Surgery Procedures Page 67 of 100

68 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Ganglion Category Restricted GANGLION A ganglion is a non-cancerous fluid-filled lump which can occur near joints or tendons. It is most commonly found on the wrist or hands. The cyst can range from the size of a pea to the size of a golf ball. Ganglions can occur alongside any joint in the body, but are most common on the wrist (particularly the back of the wrist), and the hand and fingers. Ganglions are harmless, but can sometimes be painful. If they do not cause any pain or discomfort, they can be left alone and may disappear without treatment, although this can take a number of years. The two main treatment options for a ganglion cyst are: draining fluid out of the cyst with a needle and syringe the medical term for this is aspiration cutting the cyst out using surgery Eligibility Criteria Surgical treatment of ganglia is restricted. The CCG will fund this treatment if the patient meets the following criteria: Surgery for ganglia will be funded where painful lump causing disabling pain and restricting activities of daily living and/or work; Surgery for mucous cysts will be funded when causing distortion of nail growth and discharge predisposing to septic arthritis. This is because a ganglion will often disappear on its own after a year or two. The Royal College of Surgeons advises that if the Ganglion is not causing any trouble that it is best to be left alone. This means for patients who DO NOT meet the specified criteria the CCG will only fund the Page 68 of 100

69 treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Guidance The British Society for the Surgery of the Hand Ganglion Cysts leaflet pdf NHS Choices - Ganglion cyst Page 69 of 100

70 NHS Birmingham CrossCity Clinical Commissioning Group NHS Birmingham South Central Clinical Commissioning Group NHS Sandwell and West Birmingham Clinical Commissioning Group NHS Solihull Clinical Commissioning Group Policy for Groin Hernia Repair Category Restricted GROIN HERNIA REPAIR A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall. In many cases, hernias cause no or very few symptoms, although you may notice a swelling or lump in your tummy (abdomen) or groin. The lump can often be pushed back in, or will disappear when you lie down. Coughing or straining may make the lump appear. Patients may experience pain or discomfort that can limit their daily activities. Hernias can also present as a surgical emergency should the bowel strangulate or become obstructed due to the hernia. There are many different types of hernia; this policy relates to groin (inguinal) hernias only. Groin hernias occur when fatty tissue or a part of your bowel pokes through into your groin at the top of your inner thigh. This is the most common type of hernia and it mainly affects men. It is often associated with ageing and repeated strain on the abdomen. Page 70 of 100

71 Eligibility Criteria Groin hernia repair is restricted. The CCG will fund this treatment if the patient meets one or more of the following criteria: all male patients with an overt or suspected inguinal hernia should be referred to a surgical provider except for patients with minimally symptomatic inguinal hernias who have significant comorbidity (ASA grade 3 or 4) AND do not want to have surgical repair (after appropriate information provided) male patients with irreducible and partially reducible inguinal hernias male patients who experience pain or discomfort that limits daily activities male patients with suspected strangulated or obstructed inguinal hernia should be referred as an emergency all children <18 years with inguinal hernia should be referred to a paediatric surgical provider all inguinal hernias in women should be referred urgently This means for patients who DO NOT meet the specified criteria the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. Note: The ASA physical status classification system is a system for assessing the fitness of patients before surgery. In 1963 the American Society of Anesthesiologists (ASA) adopted the five-category physical status classification system; a sixth category was later added. These are: 1. Healthy person 2. Mild systemic disease 3. Severe systemic disease 4. Severe systemic disease that is a constant threat to life 5. A moribund person who is not expected to survive without the operation 6. A declared brain-dead person whose organs are being removed for donor purposes Page 71 of 100

72 Primary Care Pathway Page 72 of 100