public involvement in the identification of low ....doc

12th January 2007Kestrel House

Hedgerows Business ParkColchester Road

ChelmsfordEssex

CM2 5PF

Tel: 01245 398770Fax: 01245 398712

Dear Colleague

Clinical and Patient/Public Involvement in the Identification of Low Priority Procedures

Mid Essex PCT is currently clarifying its health policies for designating treatments as low priority and is requesting comments from clinicians and patients to contribute to this work.

A process of determining low priority treatments, based on evidence of effectiveness, has been developed by the public health team and endorsed by the PCT Professional Executive Committee.

The aim of this work is to maximize the effectiveness of the treatments which the PCT commissions by limiting access to those treatments where there is little or no evidence of effectiveness. This will have outcomes both in terms of clinical effectiveness and in freeing up resources to be channelled to more effective interventions.

This is an important piece of work for the PCT, its patients and all local clinicians. It will have a direct impact on patient care and on the financial situation within the health economy.

Both primary care and hospital clinicians are important in ensuring that patients are referred and treated appropriately. Patients are key partners in decisions about their care. It is important that those who have an interest in this work have the opportunity to comment

We hope that you will appreciate, as we do, the importance of this work and will be able to send us your comments on the attached draft list of procedures which may be designated low priority. The list will also be available on the Public Health section of the PCT website under Trust documents section.

A reply slip is attached for your convenience. Please email comments to [email protected] by Thursday 6th February 2007.

Yours sincerely

Jan YatesPublic Health

mailto:[email protected]

Clinical and Patient/Public Involvement in the Identification of Low Priority Treatments

Comments on the draft list of low priority procedures

Comments on the proposal to expand the list of low priority procedures, basing new policies on evidence of effectiveness

Comments on specific clinical policies proposedPolicy Comment

Mid Essex PCT Clinical Prioritisation Policies – Draft 4Draft 4 prepared by Jan Yates, January 2006.

Table. Draft list of procedures which may be designated low priority for Mid Essex based on evidence of effectiveness (Includes those treatments where a referral threshold can be set)

This list has been derived from:1. Policy statements from other PCTs which have been based on evidence of effectiveness. 2. Restatements of policies currently in effect across Essex.

Clinical and PPIF engagement and comment is important before the PCT Board ratifies these policies.

This list includes two categories of procedure: Those which, as routine are not provided by the PCT and where provision is only possible on an individual patient basis, via the referral of

the case by the relevant clinician to the PCT Exceptional Cases Panel. These are listed as “PARTIALLY EXCLUDED PROCEDURE (PE)” In this case the criteria list form guidance to referring clinicians and the Exceptional Cases Panel on what may be considered exception but the final decision rest with the Exceptional Cases Panel.

Those which may be offered on a routine basis but only for patients who meet defined criteria. These are listed as “THRESHOLD APPLIES (TA)”. The responsibility for adherence to these policies lies with the referring and accepting clinicians and prior approval should be sought where this is part of the contracting arrangements.

Sources:TVPC = Thames Valley Priorities CommitteesSuffolk Low Priority Procedure ListCambridgeshire Clinical Priorities PoliciesNorfolk policiesBedfordshire and Hertfordshire policies

Procedure and type of restriction

Criteria which may be considered suitable for funding Evidence briefing/rationale available?

Origin of policy

COSMETIC AND LIFESTYLE

1 Cosmetic surgery (general principles)

Referrals for plastic surgery from both primary and tertiary sources will be assessed in line with the Service Restriction Policy and the clinical evidence provided.

For an authorised first appointment, the Plastic Surgery Specialist to whom the referral is subsequently passed should decide whether the patient would benefit from plastic surgical intervention, and if so, establish that the patient fully understands the risks and benefits of surgery.

All referrals should be assessed for both first OPD appointments and subsequent procedure appointments, in line with the policy and clinical evidence.

Cosmetic surgery undertaken exclusively to improve appearance should not be funded in adults, in the absence of previous trauma, disease or congenital deformity.

Assessment of patients being considered for referral who have an underlying genetic, endocrine or psychosocial condition should have had this fully investigated by a relevant specialist prior to the referral to plastic surgery being made.

Referrals within the NHS for the revision of treatments originally performed outside the NHS will not usually be permitted. Referrers should be encouraged to re-refer to the practitioner who carried out the original treatment.

Surgery should be supported where a patient has been accepted onto an NHS waiting list prior to taking up residence in Mid Essex, providing the existing clinical evidence has remained the same.

Where a patient has previously had NHS funded treatment, procedures necessary for dealing with complications or an outcome that, because of complications or technical difficulties, has resulted in cosmetic or physical problems that, from a professional point of view, are severe enough to oblige the NHS to fund corrective treatment should be supported.

An undesirable outcome from an aesthetic perspective and the questions of whether revision should be funded is an issue that the referrer should discuss with the patient prior to referring on to plastic surgery.

The National Service Framework for Children (National Service Framework for Children, Young People and Maternity Services. DH October 2004), defines childhood as ending at 19 years. Funding for this age group should only be considered if there is a problem likely to impair normal emotional development. Children under the age of five rarely experience teasing and referrals may reflect concerns expressed by the parents rather than the child, which should be taken into consideration prior to referral. Some patients are only able to seek correction surgery once they are in control of their own healthcare decisions and again should be taken into consideration prior to referral.

Essex service restriction policy

1 Abdominoplasty or Apronectomy

Abdominoplasty and apronectomy may be offered to the following groups of patients who should have achieved a stable BMI between 18 and 27 Kg/m² and be suffering from sever functional problems:

Essex service



Origin of policy

(PE) Those with scarring following trauma or previous abdominal surgeryThose who are undergoing treatment for morbid obesity and have excessive abdominal folds (generally a weight loss of 10 points on the BMI scale)Previously obese patients who have achieved significant weight loss and have maintained their weight loss for at least two yearsWhere it is required as part of abdominal hernia correction or other abdominal wall surgery

Severe Functional problems include: Recurrent intertrigo beneath the skin fold Experiencing severe difficulties with daily living i.e. ambulatory restrictions. These patients will need full

assessment by the appropriate professional e.g. OT. Prior to referral Where previous post trauma or surgical scarring (usually midline vertical or multiple) leads to very poor

appearance and results in disabling psychological distress or risk of infection. Abdominal wall prolapse with proven urinary symptoms Problems associated with poorly fitting stoma bags

restriction policy

2 Other skin excision for contour

(PE)

Buttock lifts, thigh lifts and arm lifts (brachioplasty), procedures will only be funded in exceptional circumstances. Essex service restriction policy

3 Liposuction

(PE)Liposuction may be useful for contouring areas of localised fat atrophy or pathological hypertrophy e.g. multiple lipomatosis, lipodystropies. Liposuction is sometimes an adjunct to other surgical procedures. It will not be funded simply to correct the distribution of fat.


4 Acne Vulgaris

(PE)The treatment of active acne vulgaris should be provided in primary care or through a dermatology service.Patients with severe facial post-acne scarring can benefit from resurfacing and other surgical interventions, which may be available from the plastic surgery service. All resurfacing techniques, including laser, dermabrasion and chemical peels may be considered for post-traumatic scarring, including post surgical and serve acne scarring once the active disease is controlled. This will need to be evaluated as being inactive by the referrer.




Origin of policy

5 Benign Skin Lesions

(PE and T)

A patient with a skin or subcutaneous lesion that has features suspicious of malignancy must be referred to an appropriate specialist for urgent assessment.

Clinically benign skin lesions should not be removed on purely cosmetic grounds. This will include: Benign Pigmented Moles: Comedones: Corn/Callous: Lipoma Male Pattern Baldness: Hirsuitism: Sweating/ hyperhidrosis (see policy later): Milia: Molluscum Contagiosum: Seborrhoeic Keratoses (Basal Cell Papillomata): Skin Tags Spider Naevus (Telangiectasia): Warts Sebaceous cysts Xanthelasma Dermatofibromas

These lesions may be funded in the following circumstances:

If a benign skin lesion has become complicated eg by infection or it is interfering with physical function and the clinician wishes to refer the patient to secondary care then funding must be approved by the PCT.

If a benign skin lesion of the eye obscures vision or is causing a separate ocular problem then the patient can be referred to an ophthalmologist for removal.

Most viral warts will clear spontaneously or following application of topical treatments.The following warts may be referred to dermatology or genitourinary medicine:

Warts on the face Warts in patients who are immunosuppressed Genital warts Painful, persistent or extensive warts, particularly in the immuno-suppressed patient, will need specialist

assessment from a dermatologist.

Facial electrolysis is a cosmetic procedure that will not be funded.

Lipomata of any size may be treated in the following circumstances:

Essex service restriction policy combined with Suffolk LPP



Origin of policy

The lipoma is/are symptomatic There is a functional impairment The lymphoma is rapidly growing or abnormally located e.g. sub-facial, sub-muscular

Patients with moderate to large lesions that cause actual facial disfigurement may benefit from surgical excision. Medical photography will be required before a funding decision can be made. The risk of scarring must be balanced against the appearance of the lesion.

Epidermoid or pillar cysts (sebaceous cysts) are always benign but some may become infected or be symptomatic. Some may require surgical excision particularly if located on the face or on a site where they are subjected to trauma.Indications for intervention might include:

Bleeding, recurrent trauma, site or size that interferes with normal day to day activity. E.g. a naevus on the bridge of the nose that interferes with the wearing of glasses.

Uncertain diagnosis Sebaceous or inclusion cysts with a past history of repeated infection. Cysts on the scalp or other body parts should be managed in the context of the minor operations/general

surgery. Funding will be considered for: Treatment of diabetic injection sites Pathological lipodystrophy

Multiple neurofibromatosis will be funded for plastic surgery.

Port wine stains on the face will be funded for removal. Port wine stains on other parts of the body that are causing physical discomfort or are resulting in tissue hypertrophy should be funded.The threshold for agreeing funding will be lower in patients under the age of 19 years.

Treatment should be considered for other haemangiomatous or vascular lesions should be funded if: There are physical problems such as bleeding or ulceration The lesion is on the face and is unusually prominent and is getting bigger.

Patients with xanthelasma should always have their lipid profile checked before referral to plastic surgery.Many xanthelasmata may be treated with topical TCA or cryotherapy. Larger lesions or those that have not responded to these treatments may benefit from surgery if the lesion is disfiguring. Clinical evidence that previous treatment has been pursued before referral has been made will be required.



Origin of policy

6 Rhinophyma

(PE)The first-line treatment of the nasal skin condition is medical. Severe cases or those that do not respond to medical treatment may be considered for surgery or laser treatment.


7 Tattoo Removal

(PE)The funding for removal of tattoos will be considered in the following circumstances:

Funding should be considered for allergy to pigments Where the tattoo is the result of trauma, inflicted against the patient’s will The patient was not found to be Fraser (formally Gillick) competent, and therefore not responsible for their

actions, at the time of the tattooing. Exceptions may also be made for tattoos inflicted under duress during adolescence or disturbed periods

where it is considered that psychological rehabilitation, break up of family units or prolonged unemployment could be avoided, given the treatment opportunity. (Only considered in very exceptional circumstances where the tattoo causes marked limitations of psychosocial function). Psychiatric/psychological reports will need to be provided with the initial referral.


8 Scar Revision

(PE)Scars that are resulting in physical disability due to contractors, tethering or recurrent breakdown will be funded.

Keloid scars, due to an over vigorous reaction in a scar, is more common in certain parts of the body and in certain racial groups.

Funding will be available for: Keloid scars that result in physical distress due to significant pain or pruritis Significant keloid scarring on the face Keloid scarring following ear piercing

Funding will not be available for: Keloid scars on other parts of the body Keloid scars secondary to body piercing procedures

Scars secondary to trauma/accidents

Scars on the face that are ragged, over 2cm in length or can otherwise be regarded, as particularly disfiguring will be funded.Scars on the rest of the body. Scar revision for cosmetic purposes will not be funded unless the disfigurement can be regarded as particularly grave. Cases will be judged on an individual basis.

In both cases, medical photography will be required with the initial referral.

Scars as a result of self-harm

These are very difficult to treat and usually the only achievable outcome is to make the scars resemble trauma or




Origin of policy

burns rather than be obviously due to self-harm. Treatment will only be funded when there has been a minimum period of three years where there has been no self-harm and where there is a supporting report from a psychiatrist indicating that the behaviour would be unlikely to recur.



Origin of policy

9 Face lifts and brow lifts (Rhytidectomy)

(PE)

These procedures will be considered for treatment of: Congenital face abnormalities Facial palsy (congenital or acquired paralysis) As part of the treatment of specific conditions affecting the facial skin e.g. cutis laxa, pseudoxanthoma

elasticum, neurofibromatosis To correct the consequences of trauma To correct deformity following surgery They will not be available to treat the natural processes of ageing.


10 Blepharoplasty (upper and lower lid)

(PE)

Upper LidThis procedure will be funded to correct functional impairment (not purely for cosmetic reasons)Indications:

Impairment of visual fields in the relaxed, non-compensated state. Evidence will be required that that eyelids impinge on visual fields reducing field to 120° laterally and 40° vertically

Clinical observation of poor eyelid function, discomfort, e.g. headache worsening towards end of day and/or evidence of chronic compensation through elevation of the brow

Lower LidThis will be funded for correction of ectropion or entropian or for the removal of lesions of the eyelid skin or lid margin.

(Suffolk Cosmetic and Lifestyle)

Essex service restriction policy amended using Suffolk LPP

11 Rhinoplasty

(PE)Rhinoplasty should be funded for:

Problems caused by obstruction of the nasal airway Objective nasal deformity caused by trauma Part of reconstructive head and neck surgery Correction of complex congenital conditions e.g.cleft lip and palate

Patients with isolated airway problems, in the absence of visible nasal deformity, should be referred initially to an ENT consultant for assessment and treatment.


12 Pinnaplasty/ Otoplasty

(PE)

The following criteria should be met for funding to be made available: The patient must be between the ages of 5 and 14 years at the time of referral

Patients seeking pinnaplasty should be seen by a plastic surgeon and following assessment, if there is any concern, assessed by a psychologist


13 Repair of external ear lobes

(PE)

This will not be routinely funded other than primary suture post trauma (Suffolk Cosmetic and Lifestyle)

Essex service restriction policy/Suffolk



Origin of policy

14 Aesthetic Facial Surgery

(PE)

Funding should be considered for: Anatomical abnormalities in children <19 years, likely to cause impairment of normal emotional development Pathological abnormalities Correction of post traumatic bony and soft tissue deformity of the face


15 Alopecia

(PE)Funding will be available when it is a result of previous surgery or trauma including burns Essex

service restriction policy

16 Male pattern baldness

(PE)

Is excluded from funding. Essex service restriction policy

17 Hair transplantation

(PE)Will not be funded, regardless of gender, other than in exceptional cases, such as reconstruction of the eyebrow following cancer or trauma.


18 Hair depilation

(PE)Hair depilation will be funded for patients who:

Have undergone reconstructive surgery leading to abnormally located hair-bearing skin Those with a proven underlying endocrine disturbance resulting in Hirsutism e.g. polycystic ovary syndrome Are undergoing treatment for pilonidal sinuses to reduce recurrence


19 Breast Reduction

(PE)Breast reduction surgery is an effective intervention that should be funded if the following criteria are met:

The patient is suffering from neck ache or backache. Clinical evidence will need to be produced that this has been investigated to rule out any other medical/physical problems to cause these symptoms

The wearing of a professionally fitted brassiere has not relieved the symptoms Persistent intertrigo Serious functional impairment The patient has a BMI of less than 30 kg/m² (or the patient is male with hormonal or drug related breast growth)

Patients should have an initial assessment by the referrer 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, to assess if this alone will relieve the symptoms experienced by the patient. Assessment of the thorax should be performed, including the use of x-ray, scan etc.


Essex service restriction policy amended using Suffolk LPP

20 Breast augmentation

(PE)

Augmentation will only be performed for reconstructive purposes and will not be carried out for small but normal breasts or for breast tissue involution, including post partum changes.




Origin of policy

21 Asymmetry

(PE)Funding will only be considered if there is gross disparity of breast cup sizes on initial consultation with the patients GP.


22 Revision of Breast Augmentation

(PE)

Revisional surgery is carried out for implant failure, causing proven health problems the decision to replace the implants rather than simply remove them should be based upon the clinical need for replacement and whether the patient meets the criteria for augmentation at the time of revision.

Replacement should not be funded if the original operation was done for cosmetic reasons in the private sector, although it would be acceptable to replace implant failures with an implant purchased by the patient


23 Mastopexy (Breast Lift)

(PE)

This is included as part of the treatment of breast asymmetry and reduction but not for purely cosmetic/aesthetic purposes such as post-lactational ptosis.


24 Nipple Inversion

(PE)Nipple inversion may occur as a result of underlying breast malignancy. If the inversion is newly developed, it requires urgent referral and assessment.

Surgical correction of nipple inversion should only be available for functional reasons in a post-pubertal woman and if the inversion has not been corrected by correct use of a non-invasive suction device.


24 Gynaecomastia

(PE)Surgery to correct gynaecomastia should be allowed if the patient is:

Post pubertal Normal BMI < 25 Kg/m2

True gynaecomastia that is mainly caused by an excess of glandular breast tissue will be funded if the normal medical treatments have failed. Re assurance that the problem is not due to the abuse of drugs with bodybuilding.

Pseudo-gynaecomastia, where the enlargement of the male breast is due to an excess of adipose tissue and the BMI is outside the range of a normal BMI, funding will not normally be agreed unless there is clear evidence that the problem has persisted in spite of rigorous dieting and weight loss.


26 Reversal of male sterilization

(PE)

Funding will only be considered if death of an existing child of the man has occurred, OR remarriage following death of spouse, OR loss of unborn child when vasectomy had taken place during the pregnancy.


Suffolk LPP policy

27 Reversal of female sterilization

(PE)

Funding will only be considered if death of an existing child of the woman has occurred, OR remarriage following death of spouse,


Suffolk LPP policy

28 Treatment for gender dysphoria

As there is currently insufficient evidence on the risks and benefits of gender reassignment this procedure should only be considered under exceptional circumstanced. These are some of the criteria that would be taken into account before funding the procedure.

(Suffolk Cosmetic and

Suffolk LPP policy



Origin of policy

(PE)Referrals should be made by a consultant psychiatrist. A written recommendation will be needed from the psychiatrist, who should have had clinical responsibility for the patient for at least 6 months. Referrals should not be accepted directly from GPs or other professionals.

Prior to genital sex reassignment the patient will also need to be seen by a consultant urologist to identify and possibly treat abnormalities of the genito-urinary tract. This is commonly accepted as good practice.

Prospective patients should be required to live and work for at least two years in the social role of the opposite sex. This is referred to as the "real life" test.

Lifestyle)

29 Assisted conception using IVF/ICS/IUI for infertility

(T)

Intrauterine insemination (IUI) is considered a low priority treatment for couples who are mutually eligible for both in-vitro fertilisation (IVF) and IUI and will only be provided under the NHS when there is strong patient preference for IUI.One full cycle of (IVF) intracytoplasmic sperm injection (ICSI) will only be provided under the NHS to couples who satisfy the eligibility criteria. Referrals should be made to a hospital consultant with a special interest in infertility for investigation and then to the Isis Fertility Centre if criteria are met.This policy does not cover preimplantation genetic diagnosis or cryopreservation of gametesand/or embryos.Criteria for funding:1. Maximum FSH level 15 U/L.2. Minimum maternal age 23 years at the start of super-ovulation.3. Maximum maternal age 39 (ie < 40) at the start of super-ovulation.4. Maximum BMI 30 kg/m2.5. Minimum BMI 19 kg/m2, if anovulatory.6. Duration of sub-fertility: No criterion for cases with a diagnosed severe cause of infertility; 3 years for cases with unexplained or mild-moderate cause of sub-fertility.7. Previous IVF treatment: Ineligible if there have been 3 or more unsuccessful previous fresh embryo cycles (either NHS or self-funded).Donor insemination: Ineligible if 12 or more unsuccessful previous cycles (however funded).8. Smoking status. Where a couple smoke, only couples who agree to take part in a supportive programme of smoking cessation will be accepted on the IVF treatment waiting list and should be nonsmoking at time of treatment.9. Parental status Couples are ineligible if there are any children from current relationship. Priority should be given to childless couples (i.e. no previous children for either partner).10. Previous sterilization has taken place (either partner), even if it has been reversed.11. Child welfare Couples should conform to statutory ‘Welfare of the Child’ requirements.12. Medical conditions Treatment may be denied on other medical grounds not explicitly covered in this document.A “full cycle’ of IVF (IVF/ICSI) includes one ‘fresh embryo’ cycle (when appropriate including egg donation subject to UK availability of donor eggs, sperm donation in the context of subfertility, or surgical sperm retrieval).


Suffolk LPP policy combined with current Essex-wide policy

30 Endoscopic thoracic sympathectomy for

Will not be routinely funded TVPC



Origin of policy

excessive sweating and/or facial blushing

(PE)ENT

31 Treatment for snoring

(PE)

Radiofrequency ablation should not be used for snoring.Laser treatment will only be considered for snoring in the context of treatment under specialist supervision for obstructive sleep apnoea.

Suffolk LPP policy

32 Grommets / Adenoidectomy

(T)

A period of watchful waiting is the best management strategy for children with otitis media with effusion. Grommets should only be considered for patients satisfying defined criteria. Patients and parents should be advised of the risk of potential harm e.g. tympanosclerosis.Children with hearing impairment should have a period of at least 6 months of watchful waiting from the onset of the symptoms.Grommet should only be considered if A - glue ear persists, and the child (3 years or over) also suffers from one of the followings:

1. Recurrent acute otitis media with more than 5 times per year.2. Evidenced delay in speech development3. Educational or behavioural problems attributable to persistent hearing impairment, with a hearing loss of at

least 25dB particularly in the lower tones (low frequency loss4. A second disability, such as Down’s syndrome5. Severe collapse of the eardrum

OrB. the child has had at least 5 occurrences of acute otitis media in the last year with additional complications such as perforations, persistent discharge, febrile convulsions, sensorineural deafness or cochlear implantation.OrC. for children aged 2 years, the child has:

OME with prolonged effusion (6 months or longer); AND measured hearing loss; AND disability attributable to hearing loss (delay in speech development or other problems).

Indications 1-5 are similar to the referral guidelines outlined in ‘Prodigy’.Combine adenoidectomy and grommet insertion if the child has nasal symptoms on top of otitis media with effusion

Suffolk LPP policy (with Newcastle period of 6 months, Suffolk has 3)Combined with Cambs draft policy

33 Tonsillectomy

(T)A six-month period of watchful waiting is recommended prior to tonsillectomy to establish firmly the pattern of symptoms and allow the patient to consider fully the implications of operation.

Patients should meet all of the following criteria: sore throats are due to tonsillitis five or more episodes of sore throat per year

Suffolk combined with Cambs



Origin of policy

symptoms for at least a year the episodes of sore throat are disabling and prevent normal functioning.

OR the patient should have: intractable cough with a high level of streptococcal antibody; OR severe halitosis which has been demonstrated to be due to tonsil crypt debris.

Note should also be taken of whether the frequency of episodes is increasing or decreasing.Tonsillectomies for other indications will need to go via exceptional cases panel before surgery is undertaken. Other indications for Tonsillectomy that the exceptional cases panel may consider include:Sleep apnoea (demonstrated by a sleep study or other accepted method of diagnosis). Significant failure to thrive in children.

Once a decision is made for tonsillectomy, this should be performed as soon as possible, to maximise the period of benefit before natural resolution of symptoms might occur (without tonsillectomy).GENERAL SURGERY

34 Bariatric surgery

(PE)Funded patients are those who fulfill criteria for treatment under NICE guidance. Treatment will not be funded without prior approval of the EFP panel. Treatment should be carried out in accordance with NICE guidance.

The NICE guidance includes the following:

It is recommended that patients with morbid obesity who are considering surgery to aid weight loss should discuss the treatment with the specialist responsible for their treatment. This discussion should cover, in detail, the potential benefits, risks and complications of having surgery to aid weight reduction.

NICE has recommended that surgery to aid weight loss should be available as a treatment option for people with morbid obesity provided that they meet all of the following criteria

They are aged 18 years or over They have tried all other appropriate non-surgical treatments to lose weight but have not been able to lose

weight or maintain weight loss There are no specific medical or psychological reasons why they should not have this type of surgery They are generally fit enough to have an anaesthetic and surgery They should understand that they will need to be followed-up by a doctor and other healthcare professionals

such as dieticians or psychologists over the long-termPeople with morbid obesity should have surgery to aid weight loss only after they have had a full assessment by the specialist and other healthcare professionals involved in their care. In addition, counselling and support should be arranged for people before and after the surgery. Smoking cessation advice should be offered as necessary.

Suffolk LPP policy

35 Varicose vein surgery or injection

Any patient presenting to their GP with Varicose Veins shall be referred directly to the Tier 2 Varicose Vein Assessment service. Any patient who is referred directly to MEHT with varicose veins shall be redirected to Tier 2 for assessment.

Suffolk LPP policy



Origin of policy

(T)Surgery or injection will not be performed unless the patient meets one or more of the following criteria:

Patient has varicose eczema which has not responded to the regular use of compression hosiery for a period of six months

Patient has lipodermatosclerosis or ulcer Patient has had at least two episodes of superficial thrombophlebitis Patient has had two minor episodes of bleeding from a varicosity or one major episode Patient has significant aching, discomfort or oedema in the affected leg(s) that is thought to be due to

varicose veins, requires analgesia (in the case of aching or discomfort) and has not responded to the regular use of compression hosiery for a period of six months.

36 Endoscopy(T)

Awaiting regional policyAll patients requiring routine diagnostic and screening endoscopy should be referred directly to the Tier 2 Community endoscopy service. Any patient who is referred directly to MEHT shall be redirected to Tier 2 for assessment.

Beds/Herts policy:Criteria for upper GI endoscopy for the investigation of dyspepsia should be based on NICE guidance1:Urgent specialist referral for endoscopic investigation is indicated for patients of any age with dyspepsia when presenting with any of the following:· chronic gastrointestinal bleeding· progressive unintentional weight loss· progressive difficulty swallowing· persistent vomiting· iron deficiency anaemia· epigastric mass or suspicious barium meal.Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, in patients aged 55 years and older with unexplained and persistent recent onset dyspepsia alone despite treatment, an urgent referral for endoscopy should be made.

Relevant OPCS code(s): G16, G19, G45

Audit note: These OPCS coded procedures will also be used for other indications, so audit ofimplementation of guidance should be specific to dyspepsia.

Beds/Herts

37 Non-urgent elective surgery for smokers

Elective surgery will not be carried out (unless urgent) on patients unless they have attended a course of stop smoking support (provided either by the specialist stop smoking service or in primary care)Patients who have not achieved smoke free status for 3 months are not excluded from referral – this is down to clinical judgment of risks and benefits. It is recognised that exceptional individual circumstances may require clinical judgement that the referral may be necessary.

SHA adviceLondon Health Observatory Evidence



Origin of policy

MUSCULOSKELETAL

38 Spinal surgery:Endoscopic laser spinal surgery, percutaneous intradiscal electrothermal therapy(PE)

Exceptional patients are those who fulfill criteria for treatment under NICE guidance.The only indications for this spinal surgery to be considered are those from NICE guidance (IPG027, IPG031, IPG061, IPG088, IPG081) and must conform to this guidance ie should not be used without special arrangements for audit, consent and research.

IPG061 Percutaneous endoscopic laser thoracic discectomy is used to treat symptomatic thoracic disc herniation.

IPG027 Laser lumbar discectomy is considered when there is nerve compression or persistent symptoms that are unresponsive to conservative treatment. Laser discectomy can be performed when the prolapse is contained. It is one of several minimally invasive surgical techniques, which are alternatives to open repair procedures such as open lumbar discectomy or laminectomy.

IPG031 endoscopic laser foraminoplasty for chronic back and leg pain from a variety of causes. IPG088. Endoscopic division of epidural adhesions for lower back pain, particularly when radiculopathy (a

disorder of the spinal nerve roots) is present. IPG081 Percutaneous intradiscal electrothermal therapy for discogenic back pain

Suffolk LPP policy

39 Spinal surgery for non-acute lumbar conditions(T)

Patients will only receive non-acute+ spinal surgery under the following circumstances:

Surgical discectomy (standard or microdiscectomy) in selected patients with sciatica secondary to disc prolapse where conservative management for at least 4-6 weeks has failed.

It is recommended that Primary Care Referral for assessment for spinal surgery or other invasive intervention should only be considered if radicular pain has not responded to non-invasive treatment after 4-6 weeks.

Fusion surgery for chronic low back pain may be considered if severe pain despite two years of an ‘active rehabilitation programme’ (cognitive intervention combined with exercises is recommended when available).

+ Acute conditions include back pain due to fracture, dislocation, complications of tumour or infection and/or nerve root or spinal compression responsible for progressive neurological deficit.

Suffolk LPP policy

40 Hip and knee replacement surgery(T)

Any patient presenting to their GP with hip or knee pain shall be referred directly to the Tier 2 Community Orthopaedic Service. Any patient who is referred directly to MEHT with any condition included below shall be redirected to Tier 2 for assessment.Patients should be referred for consideration of total joint replacement when all conservative means have failed to alleviate the patient’s pain and disability, which should be significantly interfering with their activities of daily living and their ability to sleep. Referral should only be for patients satisfying defined criteria.

Replacement surgery will not be performed unless all the following criteria are met: The patient is suffering from pain and disability that is sufficiently severe as to interfere with their daily life

and/or ability to sleep (eg Salisbury Score 14 or an Oxford Hip and Knee Score of 60) AND The patient has used a range of conservative treatments – analgesics, NSAIDS, exercise and physiotherapy

(as appropriate) – and these have failed to alleviate the patient’s pain AND

Suffolk LPP policy(Pain scoring from Newcastle)



Origin of policy

If obese (BMI >30), the patient has undertaken a supervised weight reduction programme with the aim of reducing the BMI to below 30.

41 Chronic hand conditions(T)

GANGLIONCystic degeneration from joint capsule or tendon sheath. Lesions at the base of the digits are often small but very tender (seed ganglion). Mucoid cysts arise at the distal interphalangeal joint and may disturb nail growth. Ganglions arising at the level of the wrist are rarely painful and most will resolve spontaneously within 5 years. The recurrence rate after excision of wrist ganglia is between 10 – 45 %.Conservative management is largely a matter of reassurance. When there is doubt aspiration will confirm diagnosis. After a first aspiration 50-80% of ganglia recur, but after a third aspiration only 20% recur.Refer

Painful seed ganglia. Mucoid cysts that are disturbing nail growth or have a tendency to discharge (risk of septic arthritis in distal

inter-phalangeal joint).There is no indication for the routine excision of simple wrist ganglia. These should not generally be referred.

CARPAL TUNNEL SYNDROMEPatients typically present with nocturnal dysaethesia in the hands wearing off with activity. The presence of a positive Phalen’s (wrist flexion test) or Tinel’s sign confirms. Nerve conduction studies are NOT generally needed to confirm the diagnosis. In elderly patients the condition may develop insidiously.Conservative treatment may include adjustment of activities or posture, with night splintage in neutral wrist position. Non-steroidal anti-inflammatory drugs and diuretics are occasionally of benefit. Steroid injections may be of value in uncomplicated cases (requires clinical experience).Refer

Acute severe symptoms (fewer than 5% of patients) uncontrolled by conservative measures, particularly in pregnancy, significantly interfere with daily activities.

Mild to moderate symptoms with failure of conservative management, (4 months) Neurological deficit ie. Sensory blunting or weakness of thenar abduction ( wasting or weakness of abductor

pollicis brevis).

DUPUYTRENS DISEASENodular or cord-like thickening of the palmar skin. May tend to cause tethering of the digits with loss of extension range.Refer

Loss of extension in one or more joints exceeding 25 degrees. Young patients (under 45 years) with disease affecting 2 or more digits and loss of extension exceeding 10

degrees.

TRIGGER FINGERSnapping of the fingers as they are extended from a fully flexed posture, associated with a tender nodule in flexor

Suffolk LPP policy



Origin of policy

tendon at base of finger or thumb. Conservative treatment may include rest from precipitating activities, Non-steroidal anti-inflammatory drugs. Injection of hydrocortisone into the tissue IN FRONT of the tendon at the level of the distal palmar crease (MCPJ) will often settle early cases (requires clinical experience).Refer

Failure to respond to conservative treatment (max 2 injections) Fixed flexion deformity that cannot be corrected

42 Temporomandibular Joint Replacement(PE)

This should not be routinely fundedIndications for intervention in rare cases with prior approval.The affected patients usually have severe disease of the temporomandibular joint which may be more serious if patients cannot open their mouths adequately, as dentistry, anaesthesia and resuscitation may be severely complicated and even life-threatening. In such rare cases, TMJ replacement may be considered. Contraindications are: 1) active or chronic infection; 2) patient conditions where there is insufficient quantity or quality of bone to support the components; 3) systemic disease with increased susceptibility to infection; 4) patients with extensive perforations in the mandibular fossa and/or bony deficiencies in the articular eminence or zygomatic arch that would severely comprise support for the artificial fossa component; 5) partial TMJ joint reconstruction; 6) known allergic reaction to any materials used in the components; 7) patients with mental or neurological conditions who are unwilling or unable to follow post-operative care instructions; 8) skeletally immature patients; and 9) patients with severe hyper-functional habits (e.g. clenching, grinding etc.).

TVPC

DRUGSFurther work is needed to ensure drug policies are incorporated into the low priority procedure listThe lists below are those in force in other PCTs

43 Drugs – secondary care (Suffolk source)(PE)

The following drugs will not be routinely funded: Infliximab for Crohns disease in children under 18 years (PE) Bevacizumab for first and second line colorectal cancer (PE) Alemtuzumab for chronic lymphocytic leukaemia (PE) Growth hormone for growth disturbance in children born small for gestational age (PE) Rituximab as first line in stage III-IV follicular lymphoma (PE) Bortozomib for relapsing, refractory myeloma (PE)

Suffolk LPP policy

44 Drugs – secondary care (other sources)(PE)

Pemetrexed for unresectable malignant pleural mesothelioma (TVPC) (PE) Pegvisomant for the management of acromegaly (TVPC) (PE) Inosine Pranobex for Chronic Fatigue Syndrome/Chronic Epstein Barr Virus Infection (TVPC) (PE) Terbinafine (& other antifungal preparations) for fungal nail infections Exceptions to this are where the

onychomycosis causes significant pain; secondary infection (cellulitis); functional impairment (eg inability to use footwear or difficulty walking) or where the patient is at significant risk of complications due to, for example, diabetes, peripheral vascular disease or immunosuppression (Beds/Herts) (PE).

Others

45 Drugs – primary care(PE)

The following drugs should not be routinely prescribed: Calcium and vitamin D (Calcichew) – use other calcium and vitamin D products (see BMF 9.6.4) Co-proximol (use paracetemol) – there may be occasions where this is used in specialist pain treatment Desloratidine (Neoclarityn) – use Loratidine or other antihistamine unless not tolerated or inadequate

List available

Norfolk grey list



Origin of policy

response Duloxetine (Cymbalta) – use other antidepressants Duloxetine (Yentreve) – may be some use in acute treatment of urinary incontinence Escitalopram (Cipralex) – use citalopram Glicazide (*modified release - Diamicron) – use standard release formulation Levocetirizine (Xyzal) – use cetirizine or other antihistamine unless not tolerated or inadequate response Malaria prophylaxis – provide using private prescription Sumatriptan as Imigran-RADIS – use off patent formulation Tramadol + paracetemol (Tramacet) – use established analgesics - there may be occasions where this is

used in specialist pain treatment 46 Drugs – primary

care(other sources)

Inhaled insulin (Oxfordshire) (PE)Primary care prescribing for subfertility should be restricted to Clomiphene, Tamoxifen and Metformin only (Current Essex policy)

Various

DENTAL

47 Dental implants(T)

Implants offer the possibility of a stable prosthesis for individuals who have suffered extensive loss of oral tissue. They can also be used to provide support for fixed bridges and individual crowns.

The technique currently used was developed by Professor Brånemark in the late 1970s and relies on the principle of osseointegration. This means that the material (titanium) of the implant is not merely tolerated by the tissues but becomes integrated within the jaw bone giving the implant firm stability. The prosthesis is then attached to the implant. With earlier blade type implants results were unpredictable with the possibility of the implant loosening within a few years of placement. Osseointegrated implants, however, have a much higher success rate.

With the increasing popularity of Professor Brånemark’s technique an increasing demand for implants is inevitable and it is important, therefore, to prioritise the categories of individuals for whom implant treatment is appropriate. The vast majority of the population can tolerate wearing dentures and these remain a successful and well-established method of replacing missing teeth.

CRITERIA

The categories of patient for whom implants should be considered are those where there is no practical alternative. The categories are: -

Patients with maxillofacial and cranial defects. These individuals have considerable amounts of missing hard tissue and/or teeth, may be due to developmental disorders, trauma or tumours. These include: Clefts of the hard and/or soft palate, Major maxillary/mandibular resections, Extensive alveolar ridge deformities

Patients with multiple congenitally missing teeth where conventional prostheses have proved to be ineffective

Patients who have suffered major trauma that cannot be restored by conventional prostheses Patients with edentulous jaw(s) who: have gross atrophy of their jaw(s) with unacceptable stability or pain

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Origin of policy

following the utilisation of appropriate specialist techniques in the constructions of the prosthesis or have problems in retaining a conventional prosthesis due to atypical movements, such as dyskinesias and Parkinson’s Disease.

Only in the most exceptional circumstances will implants be available for patients with problem dentures or who require single tooth replacement.

48 Orthodontics(T)

Patients should be referred for orthodontic care for the following categories of need:

Grade 5 Index of Orthodontic Treatment Need5a Increased overjet greater than 9mm5h Extensive hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative orthodontics.5i Impeded eruption of teeth (with the exception of third molars due to crowding, misplacement, the presence of supernumerary teeth, retained deciduous teeth and any pathological cause).5m Reverse overjet greater than 3.5mm with reported masticatory and speech difficulties.5p Defects of cleft lip and palate5s Submerged deciduous teeth.

Suffolk LPP policy

49 Wisdom teeth removal(T)

Surgical removal of impacted third molars should be limited to patients with evidence of pathology: unrestorable caries, non-treatable pulpal and/or periapical pathology, cellulitis, abcess and osteomyelitis, internal/external resorption of the tooth or adjacent teeth, fracture of tooth, disease of follicle including cyst/tumour, tooth/teeth impeding surgery or reconstructive jaw surgery, when a tooth is involved in or within the field of tumour resection.

Suffolk LPP policy

EYES

50 Filtered/coloured lenses(PE)

These will not be offered for specific reading difficulties Suffolk LPP policy

51 Photodynamic therapy (PDT) for age related macular degeneration(T)

Photodynamic therapy (PDT) should only be used in accordance with NICE guidance (TA68).

PDT should only be considered for the treatment of wet age-related macular degeneration for individuals who have a confirmed diagnosis of classic with no occult subfoveal choroidal neovascularisation (CNV) (that is, whose lesions are composed of classic CNV with no evidence of an occult component) and best-corrected visual acuity 6/60 or better. PDT should be carried out only by retinal specialists with expertise in the use of this technology.

PDT is not recommended for the treatment of people with predominantly classic subfoveal CNV (that is, 50% or more of the entire area of the lesion is classic CNV but some occult CNV is present) associated with wet age-related macular degeneration, except as part of ongoing or new clinical studies that are designed to generate robust and

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Origin of policy

relevant outcome data, including data on optimum treatment regimens, long-term outcomes, quality of life and costs.

52 Cataract surgery(T)

First eyeSurgery will not be offered for patients with visual acuity of 6/12 or better without any other significant ophthalmic pathology unless they drive or have problems with work or are unsafe because of glare

Second eye As benefits of second eye surgery have been demonstrated patients will be offered this procedure provided they full fill the referral criteria. The only exception to the above is when there is resultant anisometropia (a large refractive difference between the two eyes), which would result in poor binocular vision or even diplopia.

The following scoring system should be used to determine referral.

Assessment of visual and social difficulties:

Visual acuity

Less than 6/36 3Less than 6/18 in both eyes 3Less than 6/18 in poorer eye 2Less than 6/12 in either eye 16/9 or better but with significant visual disturbance 1

All patients scoring 3 points in this section should be referred for the worst eye

Visual disability

Affected by glare 2Difficulty with reading 1Difficulty watching television 1Difficulty performing work or hobbies 1

Social functioning (Tick ONE box only)

Lives independently 2Cares for partner 2Lives in sheltered accommodation 1Lives with carer 1Lives in a residential or nursing home 1

Based on clinical consensus

North East Essex policy combined with Suffolk LPP



Origin of policy

OtherDrives a car/is in paid employment 1Mild/moderate hearing impairment 1Severe hearing impairment (Deaf) 2Has fallen twice or more in the last 12 months 2Total points scored:

Patients with a VA score of 3 or a cumulative score of 6 or more should be referred.Please Note:Patients with retinal pathology should be referred to a general ophthalmology clinic.

53 Laser treatment of myopia(PE)

Not routinely funded N/A Norfolk

UROLOGICAL/GENITAL

54 Circumcision(T)

Circumcision should only be performed for the following indications:1. Redundant prepuce, phimosis (inability to retract the foreskin due to a narrow prepucial ring) and paraphimosis (inability to pull forward a retractedforeskin).2. Balanitis Xerotica Obliterans (chronic inflammation leading to a rigid fibrous foreskin).3. Balanoposthis (recurrent bacterial infection of the prepuce).There are several alternatives to treating retraction difficulties before circumcision is carried out. It is important that all those performing circumcision should follow the General Medical Council (GMC) guidelines.

Suffolk LPP policy

55 Prostatism(T)

Investigations will not be carried out unless the patient has one of the following: An international prostate symptom score of 8 or more Dysuria Post voided residual volume of >200mls More than one UTI Deranged renal function PSA greater than age adjusted normal values

Requested

Suffolk LPP policy

56 Vasectomies under general anaesthetic(T)

This policy is for circumstances when vasectomy should be performed under general anaesthetic. In all other cases, referral should be made to local GP based services.

Only under the following circumstances should a vasectomy be performed under local anaesthetic. In other cases a referral should be made to a primary Care Provider

Previous documented adverse reaction to local anaesthesia Scarring or deformity distorting the anatomy of the scrotal sac or content making identification and/or control

Requested

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Origin of policy

of the spermatic cord through the skin difficult to achieve57 Dilletation &

curettageHysteroscopy(T)

Patients will not receive D&C:

As a diagnostic tool for heavy menstrual bleeding, or

As a therapeutic treatment for heavy menstrual bleeding

Patients will receive hysteroscopy in the investigation and management of heavy menstrual bleeding only when it is carried out:

as an investigation for structural and histological abnormalities where ultrasound has been used as the first line diagnostic tool and where the outcomes are inconclusive

post-dilatation, pre-procedure when undertaking endometrial ablation.

Suffolk LPP policy

58 Hysterectomy(T)

Hysterectomy for heavy menstrual bleeding will only be funded when: There has been a prior trial, after appropriate clinical assessment, with a levonorgestrel intrauterine system

(Mirena®) (unless contraindicated) which has not successfully relieved symptoms. and Other treatments (such as non-steroidal anti-inflammatory agents, tranexamic acid, endometrial ablation,

uterine-artery embolisation in selected cases) have failed, are not appropriate or are contra-indicated in line with NICE guidelines.

Contraindications to the levonorgestrel intrauterine system are:1. Severe anaemia, unresponsive to transfusion or other treatment, whilst a Levonorgestrel

intrauterine system trial is in progress.2. Distorted or small uterine cavity (with proven ultrasound measurements).3. Genital malignancy.4. Active trophoblastic disease.5. Pelvic inflammatory disease.6. Established or marked immunosuppression.

For those who for ethical reasons cannot accept the use of Mirena, they should have tried at least two of the alternative treatments (above).

Cambs

(Suffolk same)

OTHER

59 Intensive inpatient therapy for severe primary lymphoedema(PE)

Intensive inpatient therapy will not be providedThere is limited evidence to support the use of manual lymphatic drainage and compression bandaging. Intensive, short term therapy using decongestive lymphatic therapy may be beneficial when combined with long term self management. These treatments are suitable for local outpatient provision.

Thames Valley Priorities Committees

60 Complementary Complementary and alternative therapies are a mixed group of therapies considered low priority treatments on the Cambridge



Origin of policy

and alternative therapies(T)

basis of weak evidence of clinical effectiveness. They will only be provided under the NHS as part of an existing service where:• The individual therapy used for a specific condition has been critically appraised.• The training and practice of the therapist is regulated by a statutory regulatory body.Complementary and alternative therapies will only be provided outside the NHS in exceptional circumstances.

Complementary and alternative therapies comprise a wide range of disciplines. We have adapted the classification recently used by the House of Lords Select Committee, which divides these therapies into three groups:Group 1 - those which are regarded as the principle disciplines:1a - with statutory regulatory control - osteopathy, chiropractic1b - acupuncture, herbal medicine and homeopathy.Group 2 - therapies used to complement conventional medicine without embracing diagnostic skills, eg massage, aromatherapy, hypnotherapy, reflexology and the Alexander Technique.Group 3a - therapies which are long established and rational in certain cultures (eg Ayurvedic medicine)3b - others with no credible evidence such as crystal therapy and dowsing.

While some evidence of effectiveness exists for therapies in Group 1, the clinical effectiveness of the majority of these therapies has not been proved with strong evidence as obtained through properly established scientific trials. Some NHSprofessionals use a selection of these therapies in their practice, eg physiotherapists using manipulation or acupuncture, or GPs using homeopathy. With effective regulatory mechanisms in place for individual professionals and under NHS clinical governance arrangements use of such therapies is acceptable.

61 Botox for hyperhidrosis(PE)

The use of Botox for the treatment of hyperhidrosis looks clinically promising (Botulinum toxin for hyperhidrosisBandolier Extra. 2002). However, Botox is only licensed for the treatment of severe axillary hyperhisdrosis and there is little evidence on which to judge it’s cost effectiveness in relation to other treatment options. Until evidence is available which demonstrates to the PCT that Botox is cost effective in relation to other treatment options it will not be routinely provided for hyperhydrosis other than axillary hyperhydrosis within the standard management of this condition.

Will be produced

Proposed new policy

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