Download Low Priority Treatment Policy

Low Priority Treatment Policy
Leicester City PCT PEC
Approved by:
On:
Review Date:
Directorate responsible
for Review:
3 October 2008
April 2010
Public Health
Policy Number:
Signed by:
…………………………………..
Low Priority Treatment Policy
Version 3 – 3.10.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
Page 1 of 13
TITLE: Low Priority Treatment Policy
VERSION CONTROL
1st Version
2nd Version
01/08/06
3 October
2008
Low Priority Treatment Policy
Version 3 – 3.10.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
Page 2 of 13
Low Priority Treatment/ Procedures Policy Guidance Notes
•
Summary of the low priority treatments and procedures where a PCT policy applies in order to safeguard the use of public monies. The PCT has a limited
budget and therefore has to prioritise what treatments will be made available to its population. These treatments and procedures are not routinely funded
under the NHS unless specific clinical needs have been identified.
•
Referrals for these treatments should not be made to secondary care unless the clinical criteria are met as described in this guidance, unless the GP
considers that the patient has exceptional clinical circumstances as defined below.
•
If the referral letter does not contain the necessary information to demonstrate that the clinical criteria are met the referral will be returned to the GP by the
Consultant / Primary Care Provider.
•
If the Consultant/ Primary Care Provider assesses the patient and considers that the clinical criteria are met and that surgery/treatment is indicated, then the
patient can be placed on the treatment waiting list.
•
All cases will be considered on an individual basis. If the GP/Consultant considers the patient to have exceptional clinical needs but are excluded under the
policy, they should make an application for funding directly to the PCT who will consider the request under the PCT Individual Cases Policy.
•
Please note that referrals within the NHS for the revision of treatments originally performed outside the NHS will be subject to the PCT Individual Cases
Policy.
•
These guidelines have been formulated following consultation with Consultants in the speciality areas and are, in part, adapted from the NHS Modernisation
Agency’s document: ‘Action On Plastic Surgery’-Information for Commissioners of Plastic Surgery Services. Referrals and Guidelines in Plastic Surgery:
http://www.wise.nhs.uk/sites/clinicalimprovcollab/surgery-plastic/Surgery%20Plastic%20Documents/1/Inclusion.pdf
(A)
Exceptional Circumstances
•
LLR PCTs accept that there may be individual cases where a patient’s clinical needs fall outside the criteria laid out in this policy and these cases will be
considered under the Leicestershire, Leicester and Rutland Individual Cases Policy.
•
LLR PCTs will use its joint commissioning principles when considering individual patients who request treatments or packages of care that are not routinely
funded under the Low Priority Policy.
Low Priority Treatment Policy
Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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•
Individual cases will not be funded where they represent a group of patients with similar clinical needs, as to do so would make new (or alter existing)
commissioning policy on behalf of the PCTs.
•
Decisions relating to groups of patients will be reached wherever possible through the annual Local Delivery Plan process within a prioritisation framework.
Therefore consideration will be given to whether an individual patient request represents a cohort (however small) of patients with similar clinical needs who
might equally wish to benefit from treatment.
•
The PCT will determine whether a case is exceptional using the following criteria:
There must be some unusual, or unique, clinical factor about the patient that suggests that they are ‘exceptional’ compared to the cohort of patients with the same
clinical condition and stage of disease. Exceptionality will be judged only on exceptional ability to benefit clinically and will not consider social factors.
The Individual Case Panel will determine whether the patient is significantly different from the cohort of patients with the same condition AND whether
there is robust evidence that this difference would result in a significantly better clinical outcome from treatment when compared to this cohort.
The consideration of whether the patient is significantly different from the cohort of patients with the same clinical condition and stage of disease will
include whether they are able to tolerate usual/standard treatments.
Low Priority Treatment Policy
Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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(B)
Policy Guidance by Speciality/Treatment
Speciality
Treatments not routinely funded
Treatments that can be directly referred
for a consultant opinion
Additional guidance notes
SKIN AND SUBCUTANEOUS CONDITIONS
Dermatology, General BENIGN SKIN OR SUBCUTANEOUS
Surgery,
LESIONS
Plastic Surgery
Treatment is not available for the
(read in conjunction with following:
section
on
laser
treatment below)
• Uncomplicated viral warts including
plantar warts (see dermatology
therapeutic guidelines)
• Seborrhoeic warts
• Molluscum contagiosum
• Acquired Spider telangiectasia/naevii
and thread-veins
• Skin tags and papillomas
• Sebaceous cysts
• Lipomas
• Haemangiomas with exception of
Port Wine Stains
• Benign moles
• Male pattern alopecia (physiological
balding in men)
• Skin ageing with no evidence of solar
keratosis, or any malignant or premalignant lesion
•
•
•
•
•
All skin or subcutaneous lesions
suspected of being malignant should be
referred urgently.
Benign skin or subcutaneous lesions that
are symptomatic i.e. they are functionally
disabling, becoming traumatised or
recurrently infected, or if there is
diagnostic doubt, can be referred
Genital warts should be referred to
Department of Genitourinary Medicine
Warts on the eyelids should be referred
directly to Ophthalmology.
Anal skin tags should be referred directly
to General Surgery.
Warts should normally be treated in
Primary Care (within the GP’s core
contract) if it is deemed that treatment is
needed (warts usually being self-limiting).
Children are defined as under the age of
18 years on the date of referral.
Sebaceous cysts:
o on the face
o over 2 cm diameter on the body
or 1cm prominence on the scalp
Port wine stains:
o adults on the face only (but
not scalp).
o children on the face (but not
scalp) or on regularly exposed
surfaces e.g. lower leg or
arms and greater than 5cms
diameter.
Lipomas
o in subfascial tissue or greater
Low Priority Treatment Policy
Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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than 5cm diameter
Dermatology/Plastic
Surgery
Vascular malformations
• Port wine stains:
o adults on the face only (but
not scalp).
Treatment is not available for the
o in children on the face (but not
scalp) or on regularly exposed
following:
surfaces e.g. lower leg or
arms and greater than 5cms
• Haemangiomas (including
diameter.
telangectasia or spider naevii) for
Rare skin conditions
either adults or children unless part of • Giant melanocytic naevii (the bathing
another significant clinical cotrunk type naevus)
morbidity.
• Naevus of Ota ( a dermal melanocytosis
• Resurfacing for skin conditions
which affects the face)
causing scarring (including post-acne • Naevus of Ito that were greater than 10
scarring)
or for
post-traumatic
cms in diameter (dermal melanocytosis
scarring
which affects the trunk)
• Hair removal (depilation) including
• Patients with rare genodermatosis e.g.
patients with an underlying endocrine
Tuberose Sclerosis
cause
• Patients with primary or metastatic skin
cancer where laser treatment offers some
significant advantage e.g. in-transit
metastatic malignant melanoma.
Recurrent Pilonidal Sinus
• To be agreed
LASER TREATMENT.
Patients must be assessed by a
Consultant Dermatologist or Plastic
Surgeon to determine:
• The potential clinical benefits of the
treatment given.
• The predicted requirements for laser
treatment and the expected clinical
outcome
Patients will be funded for an initial series
of 6, 12 or 18 treatments at the outset
dependent of the severity of the presenting
condition and predicted benefit.
The PCT will require from the provider of
the laser treatment both documentary
information on the above points and good
quality digital photographic evidence
before and after each series of treatments
that is approved.
The PCT will then determine whether to
approve further sessions of treatment in
the first instance.
Plastic Surgery
TATTOO REMOVAL.
Available where the tattoo is the result of Tattoos inflicted under duress during
trauma, inflicted against the patient’s will adolescence or disturbed periods may be
(“rape tattoo”) or on an adult who was a child considered.
under the age of consent (and not Gillick
competent) at the time of the tattooing.
Dermatology
HYPO-PIGMENTATION
The recommended treatment is cosmetic Correction of hypo-pigmentation following
laser surgery is not available in the NHS,
Low Priority Treatment Policy
Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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camouflage, available at UHL.
Dermatology/Plastic
Surgery
Vascular
Surgery/Plastic Surgery
DERMABRASION
AND/OR
RESURFACING
AXILLARY HYPERHIDROSIS
Plastic Surgery
BOTULINUM TOXIN
Treatment is not available for the
following:
•
•
Plastic Surgery
LASER
except if the laser treatment
performed under the NHS.
See notes under laser treatment
Sympathectomy may be considered in the Botulinum toxin treatment is not available
severest cases after referral to a Vascular on the NHS.
Surgeon. If this treatment fails wide excision
and skin grafting by a Plastic Surgeon may
be indicated.
Available for treatment of pathological
conditions by appropriate specialists-e.g.
Frey’s syndrome, blepharospasm, cerebral
palsy.
Axillary hyperhidrosis
Facial aging or excessive wrinkles
PLASTIC EXCISION OF SKIN FOR
COSMETIC INDICATORS (FACELIFTS,
BUTTOCK LIFTS)
See below under face, brow lifts.
Treatment is not available for the
following significant weight loss
(either following bariatric surgery or
by other means)
Plastic Surgery
was
PHOTODESTRUCTION
ELECTROLYSIS OF LESION OF SKIN.
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Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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BREAST PROCEDURES
Plastic Surgery
BREAST REDUCTION
Plastic Surgery
BREAST REDUCTION SURGERY FOR •
MALE GYNAECOMASTIA
Available where all the following criteria are
met:
• Patient is suffering neck ache,/backache
and/or debilitating recurrent intertrigo
• The wearing of a properly fitted bra has
not relieved the symptoms
• BMI is less than 30.
• Bra size of E cup or above
The referral letter must include all the above
information.
•
•
Plastic Surgery
BREAST AUGMENTATION
•
Treatment is not available for the
following:
• normal, but small, breasts or for
breast tissue involution (including
postpartum changes)
• loss of breast tissue following
significant
weight
loss
(either
following bariatric surgery or by other
means)
Post-pubertal male aged between 17-21
years at date of referral with significant
excessive breast tissue
BMI between 18-25
Patients should be screened by an
Endocrinologist prior to referral to a
Plastic Surgeon.
Women with A cup or larger breasts will
Total absence of breast tissue e.g.
• after mastectomy or other breast not normally be considered.
surgery
• major trauma to the breast during or
after development
• congenital amastia (total failure of
breast development)
• Less than bra size of A cup
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Plastic Surgery
BREAST ASYMMETRY
Plastic Surgery
BREAST
MASTOPEXY
(BREAST Available for patients who meet the agreed
UPLIFT)
criteria for breast reduction or breast
Treatment is not available for the
asymmetry (see above).
following:
• post-lactation or age-related ptosis
(droopiness)
• loss of breast tissue following
significant
weight
loss
(either
following bariatric surgery or by other
means)
Plastic Surgery
REMOVAL
IMPLANTS
OF
SILICONE
Breast augmentation may be offered to
patients with:
• unilateral absence of breast tissue after
mastectomy etc (see above for causes of
bilateral absence of breast tissue) or in
• women with a significant degree of
asymmetry of breast shape and/or
volume e.g. a difference of two cup sizes
or more between the two breasts
Surgery for the contra lateral breast will not
normally be available unless this is an
integral part of the treatment for the
asymmetry.
BREAST Implants will be removed if they are causing
significant local damage to the breast.
Replacement will be supported when:
• the original implant was put in for noncosmetic reasons.
• the original operation was an NHS
procedure.
• the risk to the patient’s health from not
replacing the implant substantially
outweighs the risk to the patient from
rupture and other complications from
putting in a new implant i.e. based on
clinical need.
• patient meets criteria for augmentation at
Low Priority Treatment Policy
Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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Plastic Surgery/Breast NIPPLE INVERSION
Surgery
time of revision (see above)
Surgical correction is only available for Underlying malignancy must always be
functional reasons in post-pubertal women if excluded
the inversion has not been corrected by
correct use of a non-invasive suction device.
Surgical correction of nipple inversion results
in ductal disruption preventing lactation.
‘Benign’ nipple inversion can improve during
pregnancy.
FACIAL PROCEDURES
Plastic Surgery / ENT
ENT/Plastic Surgery.
PROMINENT EARS IN ADULTS (18 Patient must be under the age of 18 on the
YEARS AND OVER)
date of referral
RHINOPLASTY
Only available for post-traumatic deformity
cases or as part of the correction of complex
congenital conditions e.g. cleft lip and palate.
Patients with airway problems should be first
referred to an ENT Consultant for
assessment.
RHINOPHYMA
The first line treatment is medical
ENT/Plastic Surgery
ENT/Plastic Surgery
SPLIT EARLOBES
Dermatology
HAIR REMOVAL (DEPILATION)
Plastic Surgery
FACE OR BROW LIFT
Available for the repair of totally split
earlobes as a result of direct trauma, but not
partially split lobes or elongated holes in
lobes
See notes under laser treatment
Available for patients with:
• congenital facial abnormalities
• 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
Low Priority Treatment Policy
Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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consequences of trauma
deformity following surgery;
Available to correct functional impairment as .
demonstrated by impairment of visual fields
in the relaxed, non-compensated state,
clinical observation of poor eyelid function,
discomfort e.g. headache worsening towards
the end of the day and/or evidence of chronic
compensation through elevation of the brow.
Visual field assessment may be required
•
Plastic
UPPER LID BLEPHAROPLASTY
Surgery/Ophthalmology
Plastic
LOWER LID BLEPHAROPLASTY
Surgery/Ophthalmology
Available to correct ectropium or entropium
or the removal of lesions of the eyelid skin or
lid margins
BODY CONTOURING PROCEDURES
Plastic Surgery
ABDOMINOPLASTY
Abdominoplasty is requested to remove
redundant skin folds following significant
weight loss, either due to bariatric surgery or
by other means. In these cases all of the
following criteria must be met:
• 2 years since bariatic surgery was
undertaken.
• The BMI must be less than 25 or, if this is
not achievable, the patient must have lost
at least 50% of their excess weight
(defined as the difference between their
greatest weight and their ideal weight
calculated to give a BMI of 25).
• The patient weight must have been
stable for a minimum of 1 year and the
clinician must confirm that further weight
reduction will not be possible without
removal of excess skin.
• There must be documented evidence of
Low Priority Treatment Policy
Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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significant skin pathology which is not
amenable to medical treatment
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Version 2 – 15.9.08 / Leicester City PCT: consistent with Leicester County policy that was approved September 2008
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Plastic Surgery
LIPOSUCTION
AND
OTHER •
COSMETIC
OPERATIONS
ON
SUBCUTANEOUS TISSUE.
•
contouring areas of localised fat atrophy
or pathological atrophy (multiple lipoma
stasis, lipodystrophies)
as an adjunct to other surgical
procedures.
VASCULAR PROCEDURES
Vascular surgery
VARICOSE VEIN SURGERY
•
Treatment is not available for the
following:
•
• patients with no significant trophic/skin
changes e.g venous eczema or
ulceration.
Varicose veins with significant skin
changes e.g venous eczema or
ulceration.
Two or more separate episodes of
documented superficial thrombophlebitis
Surgery is only available for patients with
significant skin changes that indicate
venous hypertension and are therefore at
risk of developing venous ulcers.
Significant skin changes include venous
eczema or ulceration. It is not available for
pain or discomfort (throbbing etc). Even in
the presence of varicose veins, most lower
limb symptoms probably have a nonvenous cause. There is a poor correlation
between leg pain and the size/extent of
varicose veins.
REVERSAL OF STERILSATION
Gynaecology, General REVERSAL FEMALE STERILISATION
Surgery, Urology
OR REVERSAL OF VASECTOMY
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