COSMETIC PROCEDURES ANNUAL REPORT 2014/15 Background Requests for cosmetic procedures from NHS Mansfield & Ashfield, NHS Newark & Sherwood, NHS North & East, NHS West, NHS Rushcliffe and NHS City are assessed by the Individual Funding Request (IFR) Officer (hosted by NHS Mansfield & Ashfield ) and a Specialist Nurse Practitioner from University Hospitals NHS Trust in line with the eligibility criteria set out in the East Midlands Commissioning Policy For Cosmetic Procedures (All Ages). A Consultant Plastic Surgeon is available ad hoc for their clinical opinion for the more challenging requests. Those requests that do not meet the eligibility criteria set out in the policy will be rejected back to the practice, outlining reasons why the referral has been declined. All rejections are followed up with a letter to the GP and the patient. Those requests where the patients meet the criteria are offered choice of hospital provider by the staff at the Clinical Assessment Service (CAS) / Referral Management Centre (RMC). New Commissioning Policy for Cosmetic Procedures (All Ages) April 2015 During 2014/15, Public Health led a review of the East Midlands Commissioning Policy for Cosmetic Procedures (All Ages) on behalf of all of the East Midlands Clinical Commissioning Groups (s). The review consisted of an evidence review, consultation with local clinicians and public and patient engagement. Clear criteria for cosmetic procedures have been developed using research evidence and clinical expert opinion, in order that funding decisions can be made rationally following proper consideration of the evidence. From 1 April 2015 a revised East Midlands Commissioning Policy for Cosmetic Procedures (All Ages) will be implemented and included in Trust contracts across the s within the East Midlands, including the 5 shire County s and City. The main changes to the policy are Labiaplasty Policy amended - not routinely commissioned, previously commissioned for patients with dysperunia. Hymen repair added into the new policy under not routinely commissioned Hair transplantation added into the new policy under not routinely commissioned for completeness. Breast implant removal/replacement Policy amended to clarify that for women who comply with the clinical criteria, and whose original surgery was funded by the NHS, replacement implants will also be inserted. (Re-insertion was not previously commissioned). Gynaecomastia wording strengthened to clarify that men with a history of use of steroids for body building or other enhancement of aesthetic or athletic performance will not be eligible for funding. Benign skin lesions wording amended to explain clinical thresholds more clearly. Septo-rhinoplasty/Rhinoplasty referring clinician asked to provide details on specific clinical criteria Varicose veins - proforma approved by local vascular surgeons is in the policy to assist GPs to make high quality referrals. Scar reduction wording slightly amended to clarify that the treatment is for keloid scars. During the last quarter of 2015, the IFR Team have attended practice manager s forums and Federation Commissioning Groups (FCG s) highlighting the changes to the new policy, referral processes and that only those patients that meet the criteria should be referred, along with the correct information as stipulated in the policy.
Analysis of requests managed in line with the Commissioning Policy for Cosmetic Procedures (All Ages) A total number of 709 requests were processed in accordance with the Commissioning Policy for Cosmetic Procedures (All Ages) during the period 1 April 2014 31 March 2015. (See Appendix 1) This is an 8.4% rise compared to 2013/14. Of the 709 referrals assessed, 334 (47%) met the eligibility criteria for NHS funded treatment and 70 (10%) were approved for an outpatient appointment for further assessment and consultant opinion. Appendix 2 gives a breakdown of the outcomes of the referral requests by. 82 referrals were rejected back to the GP practice, due to insufficient information contained within the referral, thus making it difficult to make a full assessment. The type of information that is routinely omitted included, BMI, sizes of lesions, and symptoms associated with the problem. A total number of 219 requests were sent back to the GP practice as patients did not meet the referral criteria for NHS funded treatment, making a cost avoidance of 24,528 in inappropriate outpatient appointments (based on 112 first OPA). 4 referrals were rejected back to GPs for onward referral on the 2 week cancer pathway, as there was a concern that there was a suspicion of malignancy. There were no MP letters or formal complaints received by the s in 2014-2015 about the outcome of funding decisions for cosmetics procedures. There were 17 appeals received for those requests that were declined. Abdominoplasty and gynaecomastia were the most commonly appealed requests. All decisions were reconsidered and the funding decisions were upheld (See Appendix 4). 83 requests came under other. These include procedures such as removal of foreign bodies, excision of umbilicus, repair of recti muscles and treatment for hidradenitis suppurativa. Breast Reduction/Breast Asymmetry Requests Application of 3D body scanning in breast reduction and asymmetry patients has led to a more equitable and cost-effective assessment process for patients. In the period 1 April 2014 to 31 March 2015, 54 patients were referred by their GP Practice for a body scan to determine if they were eligible for NHS funded surgical intervention. Of those requests a total of 25 (47%) referrals were rejected back to the GP Practice, as the patient did not meet the BMI eligibility criteria (18-25kg/m 2 ) to enable them to have a scan. 28 patients were eligible for a scan of which 11 patients met the eligibility criteria for NHS funded breast surgery. A total of 17 patients who were scanned did not meet the eligibility criteria, 7 for breast asymmetry and 10 for breast reduction. 1 patient did not make any contact to arrange an appointment and therefore was removed from the pathway. For those patients that did not meet the scan criteria (17) and therefore were not offered surgery, a total of 37,859 was avoided. (See Appendix 3) Priorities for 2015-2016 Work with the s contracting teams and information analysts, to monitor and ensure compliance with the Cosmetics Procedures Policy. Minimise the risk of negative media/external attention to s by maintaining and reviewing a robust decision making process. Jane Urquhart, IFR Manager Aimee Jewsbury, IFR Officer April 2015-2 -
. ** Prior approval not required - 3 -
** Prior approval not required - 4 -
** Prior approval not required - 5 -
Appendix 1 Breakdown of cosmetic procedure referrals by Procedure Mansfield & Ashfield Newark & Sherwood North & East West NHS City Rushcliffe Benign Skin Lesions* 5 25 12 5 62 8 117 Scar Reduction 12 12 11 4 45 7 91 Sebaceous Cysts** 1 8 11 5 53 7 85 Other 9 16 8 3 38 9 83 Lipoma** 2 7 8 5 30 6 58 Breast Reduction 5 7 9 5 13 6 45 Gynaecomastia 9 6 3 0 16 3 37 Breast Asymmetry 2 5 2 7 17 3 36 Procedures not routinely commissioned* 4 7 6 1 14 3 35 Abdominoplasty 8 4 4 1 13 2 32 Laser Treatment** 3 0 7 1 12 3 26 Pinnaplasty (Age 5 18)** 4 2 4 0 7 0 17 Breast Augmentation 2 2 5 1 6 0 16 Blepharoplasty 2 4 1 1 3 1 12 Breast Implant removal/insertion 2 1 2 0 3 2 10 Re-refer on 2 week wait 0 1 0 0 2 1 4 Rhinoplasty 1 1 0 0 0 0 2 Botulinum Toxin** 0 1 0 0 1 0 2 Varicose Veins** 0 1 0 0 0 0 1 TOTAL 71 110 93 39 335 61 709 *These requests include:- excision of excessive skin from all areas, other than the abdomen, facelifts, earlobe repair, mastopexy, labioplasty, liposuction, facelifts. All of these procedures are not routinely commissioned unless the treatment is: post-trauma, part of reconstruction following surgery (e.g. for cancer), part of the management of a congenital abnormality which results in a serious health function deficit, or for an iatrogenic condition arising from treatment previously delivered within the NHS. ** Prior approval not required TOTAL - 6 -
Appendix 2 - Breakdown of the outcomes of the referral requests by Summary Mansfield & Ashfield Newark & Sherwood North & East West NHS City Rushcliffe Consultant Treatment 32 49 48 14 164 27 334 Referral Rejected Does not meet criteria Referral Rejected Need more information TOTAL 30 39 30 20 85 15 219 8 9 9 4 42 10 82 Consultant Opinion 1 12 6 1 42 8 70 Re referred on 2 week wait 0 1 0 0 2 1 4 TOTAL 71 110 93 39 335 61 709 Appendix 3 Breast Reduction/Breast Asymmetry Requests Newark & Mansfield & Sherwood Ashfield Total Number of Breast Assessment Requests Received North & East West NHS City Rushcliffe 7 8 9 8 18* 4 54 TOTAL Total number of patients not eligible for scanning 4 4 4 4 7 2 25 Breast Asymmetry Scan - PASS Breast Asymmetry Scan - FAIL Breast Reduction Scan - PASS Breast Reduction Scan - FAIL 0 0 0 2 6 0 8 1 3 0 1 1 1 7 0 0 1 0 2 0 3 2 1 4 1 1 1 10 TOTAL 7 8 9 8 17 4 53 *1 patient did not make any contact to arrange an appointment and therefore was removed from the pathway. - 7 -
Appendix 4 - Appeals Appeals Mansfield & Ashfield Newark & Sherwood North & East West NHS City Rushcliffe Abdominoplasty 3 0 0 1 3 0 7 Gynaecomastia 0 0 0 0 2 0 2 Breast Reduction 0 1 0 1 0 0 2 Breast Asymmetry 0 1 0 1 0 0 2 Scar Reduction 0 0 0 1 0 0 1 Brow Bone Reduction 0 0 1 0 0 0 1 Labioplasty 0 0 1 0 0 0 1 Varicose Veins 0 1 0 0 0 0 1 TOTAL 3 3 2 4 5 0 17 TOTAL - 8 -