Download Procedures of limited clinical value

Procedures of limited clinical value
2013 - 2014
Procedures not routinely funded or requiring prior funding approval
C i t y & H a c k n e y, N e w h a m , To w e r H a m l e t s a n d W a l t h a m F o r e s t ( W E L C )
Clinical Commissioning Groups
Procedures of limited clinical value
Document revision history
Date
Version
Revision
April 2013
1
City & Hackney, Newham, Tower Hamlets,
and Waltham Forest CCGs
Comment
Author / Editor
Maggie Harding,
Consultant in Public Health
Anna Stewart, Director of
Technical Contracting
Document approval
Date
Version
April 2013
1
August 2013
1.1
Page 2
Revision
Role of approver
Approver
Clinical Commissioning
Group Governing Body
Addition of new foreword on pages 4 to 5
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Contents
Foreword ................................................................................................... Error! Bookmark not defined.
General Principles ............................................................................................................................... 6
Section 1 – interventions which require prior approval .................................................................... 8
Cosmetic and other procedures where NHS provision is low priority for WELC CCGs ............................................................................... 8
Breast procedures .................................................................................................................................................................................... 8
Cosmetic surgery - Body contouring and other cosmetic procedures ..................................................................................................... 14
Cosmetic surgery: Hair procedures ........................................................................................................................................................ 16
Cosmetic surgery: Face Procedures ...................................................................................................................................................... 18
Cosmetic Procedures: Ear Procedures ................................................................................................................................................ 201
Other cosmetic procedures that are NOT routinely funded by WELC CCGs. ......................................................................................... 21
Other: prior approval for funding is required for all these procedures ..................................................................................................... 21
Section 2 – evidence based advice to GPs ...................................................................................... 27
Cosmetic surgery - skin and subcutaneous lesions .............................................................................................................................. 257
ENT........................................................................................................................................................................................................ 29
Gynaecology .......................................................................................................................................................................................... 31
General surgery ..................................................................................................................................................................................... 34
Hand or orthopaedic surgery .................................................................................................................................................................. 35
Dental .................................................................................................................................................................................................... 41
Other ...................................................................................................................................................................................................... 42
Procedures for which access criteria have been agreed ......................................................................................................................... 41
Index ................................................................................................................................................................................................................. 42
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Procedures of limited clinical value
Foreword
This IFR policy describes the process by which City and Hackney, Newham, Tower Hamlets and Waltham Forest CCGs will make decisions on
requests to fund treatment interventions which are not routinely funded by the CCG.
This POLCV document should be read in conjunction with the IFR policy which it supplements. Procedures of limited clinical value are defined
as interventions which the CCG will not normally fund, as their usual application offers limited clinical benefit to patients e.g. cosmetic surgery.
The IFR team will review these applications against the agreed criteria or treatment threshold as appropriate as agreed by the CCG.
Recommendations which confirm patient eligibility will be presented to the lead member or manager within the CCG for determination and if
approved for funding and the applicant notified. These discussions and recommendations will take place outside of the IFR Panel through a
triage process.
Section 1 of this document lists a range of such treatments and describes the clinical circumstances in which their funding might be supported.
Prior Approval Applications
The procedures listed in Section 1 are only funded by prior approval, meaning that an application form needs to be submitted and approval for
funding given before the procedure is carried out. GPs and other clinicians wishing to secure funding for an intervention listed in Section 1 of
this document should therefore use the application form (Appendix 1) to identify the specific treatment requested, and to demonstrate how the
patient meets the clinical circumstances in which such a funding request might be supported.
IFR Applications
Standard requests for treatments listed in Section 1 will be determined by reference to the prior approval criteria listed in the document for each
intervention. However, there will be rare occasions when a patient has exceptional clinical circumstances which may justify the use of these
treatments, even if the prior approval criteria are not met. In such circumstances the application for funding will be processed according to the
CCG‟s IFR policy.
IFR applications from GPs for interventions listed in Section 1 may be made using the prior approval form in Appendix 1. Applicants will be
expected to provide clear evidence to demonstrate:
1. Evidence for the clinical effectiveness of the requested treatment for the diagnosed condition
2. How the patient‟s clinical circumstances make them exceptional compared to all other patients with the same condition
3. How the patient will receive greater benefit from the treatment than all other patients with the same condition.
Exceptional clinical circumstances require that the criteria in 2 and 3 above are demonstrated.
Processing Applications
Page 4
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
All applications against interventions listed in Section 1 must be submitted on the standard form to the Individual Funding Request team. The
CCG IFR triage lead will assess each application against the prior approval criteria for the requested intervention. Applications which do not
meet the prior approval criteria will be further assessed to determine whether a case for clinical exceptionality can be made. When clinical
exceptionality is evident, applications will be handled by the IFR route.
Introduction
This document is intended to provide guidance to clinicians regarding when to refer patients directly for treatment and is in 2 parts:
Section 1:
Includes interventions for which prior funding approval needs to be obtained. These are separated into cosmetic procedures, newly approved
procedures which merit close oversight, and low volume procedures that the Individual Funding Request (IFR) Panel has agreed are not
appropriate for routine commissioning
Section 2:
Includes a wider range of procedures where the evidence of benefit, particularly in mild cases, tends to be limited and may be less than the risk
of harm from the intervention. There is no prior funding approval for these procedures and demand management is overseen by each CCG.
Funding applications should be submitted for:
i.
all treatments included in Section 1, even if the criteria have been met
ii.
interventions in Section 1 where the patient does not meet the criteria and you feel that there are exceptional reasons why treatment should
be funded for the particular patient.
iii.
procedures for which there are agreed eligibility criteria (such as assisted conception and bariatric surgery) where the patient does not meet
the criteria and you feel that there are exceptional reasons why treatment should be funded for the particular patient
iv.
procedures not included in this guidance that are not normally funded within current CCG contracts. Should you wish to make a referral to a
voluntary or private service provider you will need to make an Individual Funding Request stating explicitly why local NHS services cannot
meet the particular patient‟s needs
v.
for several interventions, the patient‟s GP alone will not have sufficient information to complete the IFR application, including: the final points
in male and female breast reduction, most procedures in category 4, and applications before tertiary or consultant to consultant referral
(specifically Open MRI), double balloon enteroscopy; ketogenic diet for epilepsy
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Procedures of limited clinical value
The IFR service aim to process 90% of POLCV cases by 10 working days. For further information regarding this POLCV
document or the IFR process, please call 020 3688 1290, or write to us either via the secure email addresses
elcasacu.ifr.nhs.net by post to IFR Team, North and East London Commissioning Support Unit, 2nd Floor Clifton House, 75-77
Worship Street, London EC2A 2DU
General Principles
i.
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) Clinical Commissioning Groups will commit NHS resources where
there is clearly articulated need in terms of symptoms and/or clinical signs and the proposed intervention is demonstrably effective in
relieving these. It follows from this that WELC CCGs will not fund procedures aiming to give a patient the body contour or appearance that
they desire
ii.
Psychological distress alone will normally not be accepted as a reason to fund surgery.
Psychological assessment and intervention may be an appropriate intervention for patients with severe psychological distress in respect of
their body image but it should not be regarded as route into aesthetic surgery.
Only very rarely is surgical intervention likely to be the most appropriate and effective means of alleviating disproportionate psychological
distress. In these cases ideally an NHS psychologist with expertise in body image or an NHS mental health professional (depending on
locally available services) should detail all treatment(s) previously used to alleviate/improve the patient‟s psychological wellbeing, their
duration and impact. The clinician should also provide evidence to assure the IFR Panel that a patient who has focused their psychological
distress on some particular aspect of their appearance is at minimal risk of having their coping mechanism removed by inappropriate
surgical intervention.
Any application citing psychological distress will need to be supported by a current psychological assessment, which specifically addresses
current and prior engagement with appropriate psychological or psychiatric treatment
Clinicians are requested to refer to the NICE guideline on Obsessive-Compulsive Disorder (OCD) and Body Dysmorphic Syndrome (BDS)1.
Patients with this condition are not routinely funded for cosmetic surgery as the patient‟s preoccupation can be fluctuating or an episodic
course, or relapse may occur after successful treatment and may move to a different part of their body.
1
National Institute for Health & Clinical Excellence (NICE) CG31 Obsessive-Compulsive Disorder (OCD) and Body Dysmorphic Syndrome (BDS), Nov 2005.
Page 6
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
For patients with anxiety or depression, clinicians might wish to consider a referral to the local Improving Access to Psychological Therapies
service before requesting cosmetic surgery.
iii.
Bullying and disproportionate concern about personal remarks tend to be characteristics of children and adults who are vulnerable for other
reasons and these patients should be supported to develop resilience to this unacceptable behaviour from others. An offer of aesthetic
surgery to modify appearance is rarely the most appropriate NHS response. Where bullying of children is an issue, parents should work
with teachers to prevent this.
Page 7
Procedures of limited clinical value
Section 1 – interventions which require prior approval
All procedures in this Section require prior funding approval
These are separated into cosmetic procedures, newly approved procedures which merit close oversight, and low volume procedures that the
Individual Funding Request (IFR) Panel has agreed are not appropriate for routine commissioning
Cosmetic and other procedures where NHS provision is low priority for WELC CCGs
Breast procedures
1. Are not funded by WELC CCGs on cosmetic grounds or to treat the natural processes of ageing
2. WELC CCGs would not expect to receive applications for breast procedures for women younger than 18 years or men younger than 25
years unless exceptional circumstances apply
3. Because the aim of any NHS funded surgery is to relieve symptoms rather than give people the breast size or shape that they desire,
WELC CCGs will not commit NHS funds to more than one procedure per person unless prior approval has been given by the relevant
Individual Funding Request Panel
4. Given the recognised rupture rate for breast implants, all WELC CCGs‟ funding decisions for breast implants will be made by the relevant
Individual Funding Request Panel, who will need information on the precise clinical indication for unilateral augmentation rather than
contralateral breast reduction for breast asymmetry.
Page 8
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Female breast reduction
Criteria for funding
Additional information
This procedure is not routinely funded by WELC CCGs
Most women seeking breast reduction
are not wearing a bra of the correct size
and a well fitted bra may alleviate their
symptoms.
With prior approval it will be funded as below:
Bilateral breast reduction will be funded only in the following
circumstances:
1. The patient has a body mass index (BMI) of less than 28 kg/m2,
documented for at least 2 years AND
2. a bra cup size of H or more AND
3. The patient has intertrigo or shoulder ulceration from bra strap
pressure unresponsive to a minimum of 6 months standard
treatment OR
4. has neck ache, backache or lordotic posture (curvature of the
spine) for which all other causes have been excluded AND
standard analgesia AND physiotherapy documented by the GP
for at least 6 months has not improved these symptoms AND
5. The wearing of a professionally fitted brassiere has not relieved
the symptoms AND
6. A consultant surgeon has confirmed that the reduction will
exceed 500gm per side
Many women seeking breast reduction
have co-incidental back or neck pain and
so other causes need to be excluded.
Because the aim is to reduce a woman‟s
symptoms not give a women the
appearance she desires, WELC CCGs
will only fund breast reduction if a
minimum of 500g breast tissue per side
will be removed.
Unilateral breast reduction will be funded only in the following
circumstances:
7. gross asymmetry (difference in size a minimum 2 cup sizes)
AND
8. the woman‟s breasts are fully developed i.e. there has been no
change in the size of either breast over the previous 18 months.
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Procedures of limited clinical value
Treatment
Criteria for funding
Additional information
Male breast reduction
This procedure is not routinely funded by WELC CCGs. With prior
approval it will be funded in the following circumstances:
Gynaecomastia is commonly seen during
puberty and may correct once the post
pubertal fat distribution is complete if the
patient has a normal BMI. It may be
unilateral or bilateral. Rarely, it may be
caused by an underlying endocrine
abnormality or a drug related cause
including the abuse of anabolic steroids.
1. The applicant demonstrates that they have screened for and
excluded all treatable causes of gynaecomastia (drug related –
particularly abuse of anabolic steroids, endocrine) AND
2. The patient is both post pubertal AND in the case of idiopathic
gynaecomastia has had this for at least 18 months (to allow
spontaneous resolution) AND
3. gynaecomastia is causing pain unrelieved by standard analgesia
AND
4. the patient has a BMI of less than 27 kg/m2 AND
5. A consultant surgeon has confirmed that the patient has grade III
gynaecomastia (i.e. gross breast enlargement with skin
redundancy and ptosis so as to simulate a pendulous female
breast) AND the proposed reduction is greater than 100gm per
side.
Page 10
It is important that male breast cancer is
not mistaken for gynaecomastia and, if
there is any doubt, an urgent consultation
with an appropriate specialist should be
obtained.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for funding
Additional information
Breast enlargement
(augmentation
mammoplasty
This procedure is not routinely funded by WELC CCGs. Funding
may be approved by the IFR Panel for women with:
Where the application is for breast
asymmetry, the applicant will be required
to detail precisely why contralateral
breast reduction is not appropriate,
bearing in mind that the purpose of such
surgery is to relieve symptoms resulting
from difficulty with bra fitting NOT to give
women the breast size they desire (which
is cosmetic surgery).
1. congenital amastia (total failure of breast development)
unilaterally or bilaterally OR
2. significant asymmetry (difference in size of a minimum of 2 cup
sizes) of breast volume AND
3. the asymmetry is the result of:
3.1. previous mastectomy OR other excisional breast surgery
OR
3.2. trauma to the breast during or after development OR
3.3. endocrine abnormalities AND
4. the woman‟s breasts are fully developed i.e. there has been no
change in the size of either breast over the previous 18 months.
See below for WELC CCGs policy on
subsequent implant removal and
replacement which will not routinely be
available in the event of rupture or
contracture.
Page 11
Procedures of limited clinical value
Treatment
Criteria for funding
Additional information
Revision of breast
augmentation
With prior approval by the IFR Panel, this will be funded for women
only in the following circumstances:
Demand for breast enlargement is rising
in the UK. Breast implants may be
associated with significant morbidity and
women commonly need revisional
surgery (such as implant replacement)
1. If the NHS commissioned the original surgery for non-cosmetic
reasons, WELC CCGs would fund removal of the original implant
and implant replacement in the event of gross distortion caused
by implant rupture. In the event of gross distortion from other
causes a case for exceptionality would need to be clearly defined
for an IFR Panel decision
2. If the NHS did not commission the original surgery, WELC CCGs
would only fund removal of an implant where there was evidence
of imminent risk to the patient of adverse health consequences
and this would NOT include replacement of the implant
3. For PIP implants only, NHS funding for removal of ruptured
implants will only be made available:
3.1. for PIP implants inserted by a private provider where the
patient can demonstrate that her original provider is unable
or unwilling to help
3.2. for removal but not replacement of the implant.
Breast lift
Page 12
Not all patients demonstrate
improvement in psychosocial outcome
measures following breast augmentation.
These criteria are as advised by DH in
respect of PIP implants.
This cosmetic procedure is not routinely funded by WELC CCGs
either as a:
Breast ptosis (droopiness) is normal with
increasing age and after pregnancy.


Patients with breast asymmetry may
have asymmetry of shape as well as
volume, but surgical intervention for
breast asymmetry (above) is not
designed to give a patient the shape or
size of breasts they desire.
component of breast reduction surgery OR
stand alone procedure.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for funding
Additional information
Nipple inversion
Nipple inversion may occur as a result of an underlying breast
malignancy and it is essential that this be excluded.
Idiopathic nipple inversion may be
corrected by the application of sustained
suction. Commercially available devices
are available from major chemists or
online without prescription. Best results
are seen where this is used correctly for
up to three months.
Surgical correction of nipple inversion will be funded by WELC
CCGs (with prior approval) only for functional reasons in a postpubertal woman, if the inversion has not been corrected by correct
use of a non-invasive suction device.
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Procedures of limited clinical value
Treatment
Criteria for funding
Additional information
Cosmetic surgery - Body contouring and other cosmetic procedures
“Tummy tuck
(apronectomy or
abdominoplasty
This procedure is not routinely funded by WELC CCGs.
With prior approval, abdominoplasty and/ or apronectomy will be
funded following medical or surgical treatment for morbid obesity, or
other weight loss, for patients who:
1. have lost at least 50% of their excess body weight AND
2. have had a stable BMI of less than 35 Kg/m2 for at least 18
months AND
3. in the case of bariatric surgery, had their surgery at least 2 years
previously AND
4. have severe functional problems (defined opposite) from
excessive abdominal skin folds.
Patients undergoing bariatric surgery
should be clearly informed that weight
loss does not entitle them to body
contouring procedures outwith these
criteria.
„Severe functional problems‟ are defined
as:


With prior approval, abdominoplasty and/or apronectomy will be
funded for patients:
6. following trauma or previous abdominal surgery OR where it is
required as part of abdominal hernia correction or other
abdominal wall surgery AND
7. With severe functional problems (defined opposite) from
excessive abdominal skin folds
Page 14

intertrigo beneath the skin fold that
recurs or fails to respond to
appropriate medical therapy for at
least 6 months OR
severe difficulties with daily living i.e.
walking, dressing or ambulatory
restrictions which have been formally
assessed as attributable solely to the
abdominal apron OR
Disabling psychological distress that
a clinical psychologist with experience
in appearance related anxiety OR
another appropriate mental health
professional has confirmed as
disproportionate AND that surgery is
the most appropriate and effective
intervention for this.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for funding
Additional information
Other skin excision for
body contouring e.g.
buttock lift, thigh lift, arm
lift (brachioplasty)
These procedures are not routinely funded by WELC CCGs.
Patients undergoing bariatric surgery
should be clearly informed that weight
loss does not entitle them to body
contouring procedures outwith these
criteria
With prior approval, skin excision for body contouring will be funded
for patients following medical or surgical treatment for morbid
obesity, or other weight loss, who:
1. have lost at least 50% of their excess body weight AND
2. have had a stable BMI of less than 35 Kg/m2 for at least 18
months AND
3. in the case of bariatric surgery, had their surgery at least 2 years
previously AND
4. have severe functional problems (defined opposite) from
excessive abdominal skin folds.
Liposuction
„Severe functional problems‟ are:
 intertrigo beneath the skin fold that
recurs or fails to respond to
appropriate medical therapy for at
least 6 months OR
 severe difficulties with daily living i.e.
walking, dressing or ambulatory
restrictions which have been formally
assessed as attributable solely to the
excess skin OR
 Disabling psychological distress that
a clinical psychologist with experience
in appearance related anxiety has
confirmed as disproportionate AND
that surgery is the most appropriate
and effective intervention for this.
This procedure is not routinely funded by WELC CCGs.
Page 15
Procedures of limited clinical value
Treatment
Criteria for funding
Keloid scars
WELC CCGs will fund medical and excisional treatment for scars
that cause:
Additional information
1. symptoms (pain or itching) unresponsive to standard chronic
medication in non-exposed areas of the skin OR
2. significant facial disfigurement OR
3. recurrent bleeding OR
4. obstruction of an orifice OR restricts vision.
Scar revision
WELC CCGs will fund excision of hypertrophic scars and aesthetic
surgery for scar revision where scars cause:
Significant interference with function is
defined as:
1.
2.
3.
4.

significant facial disfigurement OR
recurrent bleeding OR
obstruction of an orifice or restricted vision OR
Significant interference with function (as opposite).

If psychological distress is the reason for the application, a clinical
psychologist specialising in appearance related anxiety should
confirm that the distress is disproportionate AND that scar revision is
an appropriate and effective means of addressing the psychological
distress.

difficulties with daily living e.g.
ambulatory restrictions; inability to
undertake previous employment or
caring role
risk of infection arising in a surgical
scar (usually midline, vertical,
multiple) or post trauma, that is
realistically expected to reduce as a
result of scar revision
problems associated with poorly
fitting stoma bags
Cosmetic surgery: Hair procedures
Treatment for hair loss
(alopecia
Treatment (hair grafting and flaps with/ without tissue expansion) is
not routinely funded by WELC CCGs.
Funding for treatment may be approved by the IFR Panel when the
alopecia is a result of previous surgery or trauma including burns.
Page 16
„Male pattern‟ baldness is a normal
process for many men at whatever age it
occurs.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Hair transplantation
Hair epilation (hair
removal by electrolysis or
laser
Criteria for funding
This procedure is not routinely funded by WELC CCGs.
Funding may be approved by the IFR Panel as part of the treatment
pathway for reconstruction following cancer or trauma.
Additional information
This procedure is not routinely funded by WELC CCGs.
Because WELC CCGs do not fund
maintenance treatment for hirsuitism, it is
not considered appropriate to
commission an intervention whose
effects are likely to be transitory and
psychological distress would be likely to
recur.
Funding for hair epilation may be approved by the IFR Panel for
patients who:
1. Have undergone reconstructive surgery leading to abnormally
located hair-bearing skin to the face, neck or upper chest (areas
not covered by normal clothing) OR
2. Are undergoing treatment for pilonidal sinuses to reduce
recurrence
For patients who do not meet these criteria, an IFR application will
ONLY be considered (for facial, neck or upper chest areas not
covered by normal clothing) on completion of the relevant section
explaining for the benefit of the IFR Panel why the patient differs
from the cohort of similarly hirsute patients such that they are likely
to gain more health benefit from depilation which is not available to
other similar patients.
Severe hirstutism due to an endocrine
disorder may be referred to an
endocrinology department but this is not
an indication for NHS funding of epilation.
Patients undergoing gender reassignment procedures will be
assessed in accordance with this policy as it applies to a natural
born male or female. An IFR application would need to be submitted
in this context explaining precisely why the transgender person is
likely to gain significantly greater health benefit than other patients
for whom the same procedures are not funded.
In the event that NHS funding is agreed it will be for a maximum of
six treatments.
Page 17
Procedures of limited clinical value
Treatment
Criteria for funding
Additional information
Cosmetic surgery: Face Procedures
Face lifts and brow lifts
(rhytidectomy
This procedure is not routinely funded by WELC CCGs.
Changes to the face and brow as a result
of ageing are normal
Funding will only be considered to correct:


Surgery on the upper or
lower eyelid
(blepharoplasty)
impairment of vision OR
impairment of the visual field(s) (as described in the criterion for
blepharoplasty below).
This procedure is not routinely funded by WELC CCGs.
NHS funding will only be considered to correct:
1. Impairment of visual field(s) in the relaxed, non-compensated
state where visual field test results are submitted to show that
eyelids impinge on visual fields reducing them to 1200 laterally
and 400 vertically OR
2. 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 OR
3. Significant ectropion or entropion that requires correction.
Page 18
Excessive skin in the lower lid may cause
“eyebags” but does not affect eyelid
function or vision and therefore does not
need correction.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for funding
Additional information
Rhinoplasty (surgery to
reshape the nose)
This procedure is not routinely funded by WELC CCGs.
Correction of complex congenital
conditions e.g. cleft lip and palate is
commissioned by NHS England.
NHS funding may be considered for:
1. Demonstrable obstruction of the nasal airway AND
2. significant symptoms confirmed by an ENT consultant as
resulting from nasal obstruction AND
3. symptoms that persist despite at least three months of
conservative management with, where appropriate nasal steroids
or immunotherapy.
Treatment of vascular
lesions, including port
wine stains, facial
haemangiomas and
benign acquired vascular
lesions in adults aged ≥
19 years
Interventions for these conditions are not routinely funded by WELC
CCGs because of limited evidence of effectiveness.
Any IFR application on the basis of significant facial disfigurement
should be accompanied by high quality colour photographs and a
statement that the patient is fully aware that treatment effect may be
modest.
The IFR Panel will consider each case. For all patients a very clear
statement of exceptionality would be required given that this
intervention is not routinely commissioned.
The evidence of benefit is weak, based
on poor quality studies lacking in robust
evaluation of patient satisfaction or
changes in psychosocial status.
At best the majority of patients may
achieve a 25% „lightening‟ of colour, but
with a risk of subsequent darkening of the
treated area.
Page 19
Procedures of limited clinical value
Treatment
Criteria for funding
Treatment for scarring
and skin hyper- or hypopigmentation
Interventions for these conditions including laser dermabrasion and
chemical peels are not routinely funded by WELC CCGs.
Additional information
The IFR Panel will consider each case. For all patients a very clear
statement of exceptionality would be required including the following:
1. a clear description of symptoms that the intervention is expected
to improve AND
2. all previous interventions for this condition and their impact AND
3. the relevant evidence of clinical benefit for the proposed
intervention in the underlying condition AND
4. if the application is based on facial disfigurement, high quality,
colour clinical photographs.
Cosmetic Procedures: Ear Procedures
Correction of prominent
ears (pinnaplasty/
This procedure is not routinely funded by WELC CCGs.
otoplasty
If the applicant considers there are exceptional circumstances such
that the child or young person (aged 5-19 years) is likely to gain
significantly more benefit than others with similarly prominent ears,
the IFR Panel will consider each case based on an IFR application
form that should include:
1. a clear description of reason for the IFR application AND
2. if the symptoms are distress from teasing and/or bullying, the
action parents, teachers and any other responsible adults have
taken to reduce this AND
3. provider audit data detailing evidence of benefit from pinnaplasty
in cases of similar severity, specifically in relation to distress from
teasing and/ or bullying.
Page 20
Children under the age of five rarely
experience teasing or bullying and
referrals may reflect concerns expressed
by the parents rather than the child. In
such cases the patient may benefit from
referral with their family for a multidisciplinary assessment that includes a
child psychologist.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for funding
Repair of totally split ear
lobes (or lobules)
This procedure is not routinely funded by WELC CCGs.
Additional information
Other cosmetic procedures that are NOT routinely funded by WELC CCGs.
Tattoo Removal
This procedure is not routinely funded by WELC CCGs.
Cosmetic genital
procedures (Labiaplasty)
This procedure is not routinely funded by WELC CCGs.
Transgender surgery is funded by NHS
England for patients on a recognised
NHS care programme.
Other: prior approval for funding is required for all these procedures
Page 21
Procedures of limited clinical value
Treatment
Criteria for funding
Additional information
Any procedure outside of
current NHS service level
agreements
All referrals to voluntary or private sector specialists with whom
WELC CCGs do not have a service level agreement and procedures
carried out by them require prior funding approval.
The patient should be informed before
any application is made, that WELC
CCGs would not normally fund an
intervention that is not available to all
patients with the same condition.
The application should make clear to the IFR Panel why this referral
is being made and address the following:
1. identify the local NHS commissioned service for this condition
AND
2. state why this is not appropriate for this particular patient AND
3. What the local NHS commissioned service includes AND
4. For what assessment and/or procedure funding is being sought
AND
5. The potential costs and benefits (from the provider) of the
proposed assessment and/or procedure
Reversal of female
sterilisation and reversal
of vasectomy
Reversal of sterilisation and vasectomy are not routinely funded by
WELC CCGs.
The IFR Panel will NOT consider funding, irrespective of the merits
of the individual case if:


Homeopathy
Page 22
sterilization used diathermy (female) or two widely separated
clips because reversal is unlikely to be successful: written
documentation of the original procedure should accompany any
application OR
the female partner is not demonstrably ovulating (day 21
progesterone levels)
Homeopathy is not routinely funded by WELC CCGs due to the lack
of evidence of clinical effectiveness.
The original decision on sterilisation is
assumed to have been made by mature
adults on the understanding that the
procedure is an irreversible contraceptive
choice and that each patient/couple has
been fully counseled to this effect.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for funding
Herbal medicines
Herbal medicines are not routinely funded by WELC CCGs due to the
lack of evidence of clinical effectiveness and the risk of toxicity from
non-quality assured therapies.
Acupuncture and
osteopathy
Acupuncture and osteopathy are not routinely funded by WELC
CCGs due to the limited evidence of clinical effectiveness. This
includes funding for acupuncture to treat dental pain and nausea and
vomiting.
Ketogenic diet for
epilepsy
This intervention is not routinely funded by WELC CCGs due to the
lack of evidence of clinical effectiveness.
MRI guided ultrasound
(MRgFUS) for uterine
fibroids
WELC CCGs do not routinely fund MRgFUS for uterine fibroids for:
Open MRI
This diagnostic intervention is not routinely commissioned by WELC
CCGs because scan quality is less good than from „standard MRI‟ so
diagnostic performance is less well evidenced.


fertility preservation because of lack of evidence of effectiveness
relief of symptoms because other, equally effective, better
established interventions are available.
The IFR application needs to be completed by the specialist clinician
requesting the open MRI scan because only they will be able to
explain for the benefit of the IFR Panel precisely how the results of
an open MRI scan will alter the clinical management of the patient.
Additional information
There is a routinely funded non-surgical
option (uterine artery embolisation) for
women with symptomatic fibroids who
wish to avoid surgery.
Open MRI is relatively new and before it
was introduced patients whose morbid
obesity or „claustrophobia‟ precluded
scanning were managed by alternative
means.
Page 23
Procedures of limited clinical value
Treatment
Criteria for funding
Additional information
Occipital nerve
stimulation for intractable
or cluster headache
Unless or until WELC CCGs have confirmation that this service is to
be commissioned by NHS England, this procedure will not be
routinely funded by WELC CCGs on the basis of limited evidence of
effectiveness
BASH (British Association for the Study
of Headache) 2007 Guideline Cluster
headache: “Surgical options include
implantation of occipital nerve or deep
brain stimulators, and are experimental”.
Functional electrical
stimulation for foot drop
Criteria under development (will be agreed by IFR Panel)
The NICE IPG 278 (January 2009)
suggested the procedure was sufficiently
safe (and efficacious) to be introduced
into the NHS without special
arrangements for audit, consent or
clinical governance. NICE IPGs do not
constitute an NHS funding
recommendation.
Double balloon
enteroscopy
Criteria under development (will be agreed by IFR Panel)
Non-core gender
reassignment procedures
Non-core procedures are likely to be confined to epilation.
Applications will be assessed in accordance with this policy as it
applies to a natural born male or female by the IFR Panel. IFR
applications should explain precisely why the transgender person is
likely to gain significantly greater health benefit than other patients
for whom the same procedures are not funded.
Page 24
Core procedures (assessment,
psychological support, and core surgery
– genital, breast and donor site hair
removal) are funded by NHS England
from April 2013
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Section 2 – evidence based advice to GPs
The interventions in Section 2 are a combination of:
i.
Procedures which are likely to be cosmetic and the criteria are given as guidance anticipated to ensure equity of access to services based
on significant symptoms rather than the desired appearance (benign skin lesions, varicose veins)
Procedures with a close benefit/risk balance in mild cases where initial conservative therapy is appropriate, reserving intervention for those
in whom conservative therapy does not result in improvement.
Procedures for which there are agreed eligibility criteria – assisted conception and bariatric surgery – where the patient does not meet the
criteria and you feel that there are exceptional reasons why treatment should be funded for the particular patient.
ii.
iii.
Treatment
Criteria for intervention
Additional information
Cosmetic surgery - skin and subcutaneous lesions



A patient with a skin or subcutaneous lesion that has features suspicious of malignancy must be referred to an appropriate specialist for
urgent assessment.
Some benign skin lesions will continue to be excised in hospital for differential diagnosis.
These procedures may be offered within General Practice, Community Services or Secondary Care.
Pigmented lesions
Clinically benign moles should not be referred for cosmetic reasons.
Suspicious pigmented lesions should always be subjected to
excision biopsy and sent for histology, if referred to secondary care
this should be to a pigmented lesions clinic.
Page 25
Procedures of limited clinical value
Treatment
Criteria for intervention
Additional information
Other benign skin lesions
1. Suspicion of malignancy OR
2. that is rapidly growing or abnormally located (e.g. sub-fascial,
submuscular) OR
3. significant obstruction of orifice or vision OR
4. significant functional limitation on movement or activity OR
5. where these cause itching or pain, unrelieved by standard
medication OR
6. that regularly bleed or become inflamed OR
7. lesions greater than 1cm in diameter that cause significant facial
disfigurement.
If there is any suspicion of malignancy,
patients should be referred immediately
to an appropriate service as described in
the NICE improving outcomes guidance.
These services must be part of local
hospital or specialist skin cancer multidisciplinary teams
In the interests of equity,
this policy relates to the
excision of skin lesions by
both primary and secondary
care
The following common, clinically benign skin lesions should not be
excised for cosmetic reasons:
8. Skin tags
9. Seborrhoeic keratoses
10.Hand or foot viral warts in adults
11.Comedones,
12.Corn/callouses
13.Lipomas
14.Milia
15.Molluscum contagiosum
16.Sebaceous (epidermoid or pilar) cysts
17.Spider Naevus (telangiectasia)
18.Xanthelasma
19.Neurofibromata
20.Angioma Keratoma
21.Benign Naevi
22.Haemangiomas.
Page 26
Where there is no suspicion of
malignancy, benign skin lesions are
usually self-limiting, respond to
conservative measures and have no
long-term health consequences for
patients.
The decision to remove benign skin
lesions causing moderate or severe facial
disfigurement is a balance between the
appearance of the original lesion and the
likely appearance of the surgical scar.
The decision should be made by an
experienced clinician familiar with these
factors, and excision should be carried
out by a trained practitioner in an
appropriate surgical setting.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for intervention
Additional information
1. Children between the ages of 3 and 12 years who have
documented, persistent, bilateral otitis media with effusion (OME)
AND documented persistent hearing loss on two occasions at
intervals of 3 months or more AND hearing in the better ear of
25-30 dBHL or less averaged at 0.5, 1, 2 and 4 kHz OR
2. Children between the ages of 3 and 12 years who have
documented, persistent otitis media with effusion (OME) AND
documented persistent hearing loss on two occasions at intervals
of 3 months or more AND
3. hearing loss suggestive of additional sensori-neural deafness OR
4. evidenced delay in speech development OR significant
educational, social or behavioural problems attributable to
persistent hearing impairment AND a hearing level of 25-30
dBHL or less OR
5. a second disability (e.g. Down‟s syndrome) OR
6. the otoscopic features are atypical and accompanied by a foulsmelling discharge suggestive of cholesteatoma OR
7. 5 or more episodes of acute otitis media.
See Current NICE Guidance2
ENT
Grommet (ventilation
tube) insertion
Insertion of ventilation tubes for patients of any age may be indicated
as a component of tympanic membrane repair or to preserve
function.
2



Surgery may resolve glue ear in the
short term but there is less certainty
about longer term outcomes and
large variation in effect between
children
There is debate about how best to
select children for intervention, given
the high rate of resolution particularly
in younger children
A period of watchful waiting is widely
recognized as good practice because
timing of surgery is not critical to
medium term outcome
Grommets and adenoidectomy represent
a trade off between benefits and harms;
adenoidectomy on its own is of unknown
effectiveness3
http://www.nice.org.uk/media/A8F/DC/Referraladvice.pdf
Page 27
Procedures of limited clinical value
Treatment
Criteria for intervention
Additional information
Tonsillectomy with or
without adenoidectomy
1. Suspected malignancy OR
2. Significant impact on quality of life resulting from documented
recurrent acute tonsillitis (patients or parents should keep a diary
to verify this) comprising:
2.1. Five or more episodes of tonsillitis in the preceding year OR
2.2. Four episodes/year in each of the preceding two years OR
2.3. Three episodes/year in the preceding three years AND
2.4. documented evidence of absence from playgroup, school or
work OR
2.5. failure to thrive
The frequency of sore throats reduces
with time whether or not tonsillectomy
has been performed. The benefit in the
year after operation is around 2.8 fewer
days off school and this needs to be
balanced against the risk of surgical
complications.
3. Adults with proven recurrent group A streptococcal pharyngitis
(GAHSP)4 OR
4. Documented evidence of 2 or more episodes of tonsillitis or
quinsy requiring admission to hospital OR
5. Tonsillitis exacerbating existing disease such as febrile
convulsions, guttate psoriasis, glomerulonephritis or rheumatic
fever.
6. As treatment for sleep apnoea syndrome, tonsillectomy should
only be considered for children with:
6.1. Witnessed episodes or apnoea exceeding 10 seconds OR
choking episodes during sleep AND
6.2. Daytime neuro-behavioural abnormalities or excessive
sleepiness.
3
A revised Cochrane systematic review in
2008,5 concluded that Adeno/tonsillectomy is effective in reducing the
number of episodes of sore throat and
days with sore throats in children, the
gain being more marked in those most
severely affected.
SIGN national guideline on management
of sore throat and indications for
tonsillectomy (2010) recommended
watchful waiting is more appropriate than
tonsillectomy for children with mild sore
throats.
Clinical Evidence. Review of adenotonsillectomy. 2005
Tonsillectomy versus watchful waiting in recurrent streptococcal pharyngitis in adults: Randomised controlled trial. BMJ 2007;334(7600):939-41.
5
Burton MJ, Glasziou PP. Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database of Systematic Reviews
2009, Issue 1. Art. No.: CD001802. DOI: 10.1002/14651858.CD001802.pub2.
4
Page 28
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for intervention
Additional information
Surgical treatment of
chronic sinusitis
ENT referral is appropriate for suspected:
NHS Clinical Knowledge Summaries
advise a trial of intranasal corticosteroids
for 3 months for treatment in the first
instance.6
1. complications, e.g. periorbital infection OR
2. suspected sinonasal tumour.
Referral may be appropriate if there is:
3. recurrent or chronic sinusitis of uncertain cause AND
4. unremitting or progressive facial pain AND
5. a trial of intranasal corticosteroids for three months has been
ineffective AND
6. a significant anatomical abnormality.
Sinus puncture and irrigation has a poor
diagnostic yield, and carries the risk of
secondary contamination.6
Only short-term benefit seen in patient
refractory to medical management
treated with balloon catheter dilation of
sinus ostia.7
Gynaecology
Dilatation and curettage
for heavy menstrual
bleeding in women aged
under 40 years
6
7
This is not normally funded.
This is an inappropriate procedure
because targeted endometrial sampling
is at least as accurate and has lower
complication rates. It is not a reliable
therapeutic procedure for dysfunctional
uterine bleeding for which a range of
effective medical interventions is
available (mefenamic acid,
norethisterone).
http://www.cks.nhs.uk/sinusitis/management/quick_answers#-369973 (accessed 8 February 2010)
NICE Balloon catheter dilation of paranasal sinus ostia for chronic sinusitis. IPG 273 NICE September 2008.
Page 29
Procedures of limited clinical value
Treatment
Criteria for intervention
Additional information
Hysterectomy for
menorrhagia (heavy
menstrual bleeding)
1. Documented medical contra-indication to Mirena® coil insertion
including large fibroids (uterine size >12 weeks) or distorted
uterine cavity
2. Severe anaemia, unresponsive to transfusion or other treatment
whilst a Mirena trial is in progress
3. Genital malignancy or active trophoblastic disease are rare
causes of menorrhagia
NICE clinical guidelines emphasise that:



Bartholin’s cysts
General surgery
Page 30
Significant infection and/or rapid growth causing significant pain that
is unresolved by non-surgical treatment.
The Mirena® device is effective in the
treatment of menorrhagia and is
considerably cheaper than a
hysterectomy, even if required for
many years (for contraception costs
estimated at £207 including
consultation; removal cost £26).
Other effective conservative
treatments are available as second
line treatment after failure of Mirena
or where Mirena is contra-indicated
A Cochrane systemic review showed
that the Mirena® coil improved the
quality of life of women with
menorrhagia as effectively as
hysterectomy.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Sympathectomy for
severe hyperhidrosis
(palmar, plantar, axillary)
Criteria for intervention
Additional information
Sympathectomy will only be funded if the following conditions are
met:
Sympathectomy is an established
intervention for this condition BUT should
be considered only after all other noninvasive non-surgical treatment options
have been tried and failed.
1. significant focal hyperhidrosis and a 1–2 month trial of aluminium
salts (under primary care supervision to ensure compliance) has
been unsuccessful in controlling the condition OR
2. significant focal hyperhidrosis and intolerance of topical
aluminium salts despite reduced frequency of application and use
of topical 1% hydrocortisone
AND all of the following conservative therapies have been tried and
found to be unsuitable or unsuccessful:
Compensatory sweating following
sympathectomy is common and can be
worse than the original problem.
Patients should be made aware of this
risk.
3. treatment of underlying anxiety if it is an exacerbating factor
4. referral to a dermatologist for modified topical therapy
5. prescription of oral anticholinergics (which block the effect of the
nerves that stimulate the sweat glands)
6. iontophoresis (for palmar or plantar hyperhidrosis) or botulinum
toxin injections (for axillary hyperhidrosis).
Page 31
Procedures of limited clinical value
Treatment
Criteria for intervention
Additional information
Interventions for varicose
veins
Intervention, including open surgery (ligation and stripping),
endovenous laser ablation, and radiofrequency ablation is
appropriate only for significant and intractable symptoms and signs
including:
Symptoms attributable to varicose veins
are common but their relationship to
visible trunk varices is not clear8.
1. significant bleeding from a varicosity that has eroded the skin OR
2. a prior varicosity bleed and is at risk of re-bleeding
3. an ulcer which is progressive and/or painful despite treatment
OR
4. healed venous ulceration in a patient who for clinical reasons
cannot tolerate compression stockings OR
5. after an unsuccessful 6 month trial of conservative management
(compression stockings AND exercise AND elevation several
times daily) when varicosities result in:
6. recurrent documented thrombophlebitis (2 or more episodes) OR
7. persistent skin changes (eczema or lipodermatosclerosis).
Most patients with varicose veins are
never harmed by them and good
explanation and reassurance are
fundamental.9
NICE has published detailed guidance on
what treatment should be considered for
varicose veins and when10.
Sclerotherapy is not normally funded
because of high recurrence rates.
Treatment for reticular veins and
telangectasia is generally considered to
be cosmetic (see section on cosmetic
surgery).
8 Bradbury A, Evans C, Allan P et al. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. Br Med J 1999;318:353-356
9 Campbell B. Clinical Review- Varicose veins and their management. BMJ 2006;333:287-292 (5 August)
10
NICE 2001. Referral Advice: A guide to appropriate referral from general to specialist services.http://www.nice.org.uk/nicemedia/pdf/Referraladvice.pdf
Page 32
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for intervention
Additional information
Cholecystectomy for
asymptomatic gall stones
Surgery for asymptomatic gallstones is not routinely funded as there
is limited evidence that intervention under these circumstances is
beneficial.
Approximately 10-20% of people in
western countries have gallstones, and
most (50-70%) are asymptomatic at the
time of diagnosis. Asymptomatic disease
has a benign natural course and
progression to symptomatic disease is
relatively low, ranging from 10-25%. The
majority of patients do not develop
gallstone-related complications without
first having at least one episode of pain.11
11
Gurusamy KS, Samraj K. Cholecystectomy for patients with silent gallstones. Cochrane Database of Systematic Reviews 2007, Issue 1.
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006230/frame.html
Page 33
Procedures of limited clinical value
Treatment
Criteria for intervention
Non-medical circumcision Non-medical circumcision is not routinely funded.
A service for boys aged between 6 weeks and 5 months is available
at a cost to the parent or guardian of the patient. Patients must be
resident in either Tower Hamlets, City & Hackney or Newham and
registered with a local GP.
Please contact Religious & Cultural Male Circumcision Service at
Mile End Hospital on 020 8223 8010 for further information.
Female circumcision is prohibited by under the Prohibition of Female
Circumcision Act 1995.
Surgery for varicocoele
Page 34
Persistent discomfort or pain despite adequate conservative
management.
Additional information
Circumcision is funded for medical
indications, including:
1. phimosis seriously interfering with
urine flow and/or associated with
recurrent infection
2. some cases of paraphimosis
3. suspected cancer or balanitis
obliterans
4. congenital urological abnormalities
when skin is required for grafting and
interference with normal sexual
activity in adult males
5. recurrent, significantly troublesome
episodes of infection beneath the
foreskin.
6. To restore functional anatomy after
female circumcision to facilitate
childbirth where mutilation renders
this hazardous.
There is no evidence that treating
varicocoele can help male sub-fertility
problems.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for intervention
Additional information
Hand or orthopaedic surgery
Surgical treatment of
carpal tunnel syndrome
1. Severe symptoms persisting after 3 months of conservative
therapy with local corticosteroid injection and/or nocturnal
splinting OR
2. Mild to moderate symptoms persisting after at least 4 months of
conservative therapy with local corticosteroid injection and/or
nocturnal splinting OR
3. Significant neurological deficit or median nerve denervation with
sensory blunting, muscle wasting, or weakness of thenar
abduction AND
4. Severe symptoms that significantly interfere with everyday living
activities that have been formally assessed.
Surgical excision of
ganglia
1. they are painful seed ganglia OR
2. they are mucoid cysts arising at the distal inter-phalangeal joint
and cause significant skin breakdown, significant nail deformity
or repeatedly discharge OR
3. they cause significant functional impairment and/ or pain is
unrelieved by aspiration or injection OR
4. there is diagnostic uncertainty.
Patients should be re-assured about the
benign nature of other ganglia and be
informed that:


33% of dorsal ganglions and 45% of
volar-wrist ganglia would resolve
spontaneously in six years
the recurrence rate after excision of
wrist ganglia is between 10 – 45%.
Page 35
Procedures of limited clinical value
Treatment
Criteria for intervention
Additional information
Surgical treatment of
Dupuytren’s contracture
If conservative treatment has failed to resolve:
Surgery is not curative, it aims to reduce
the chances of progression to severe
debilitating joint contractures.
1. significantly impaired function of the hand with loss of extension
in 1 or more joints that exceeds 25 degrees OR
2. at least 10 degrees loss of extension in 2 or more joints AND
3. surgery is likely to restore function.
Surgical treatment for
trigger finger
The patient has:


failed to respond to hydrocortisone injections OR
a fixed flexion deformity that cannot be corrected.
Recurrence rates after surgery range
from 26-80%.
Spontaneous recovery is reported in up
to 30% of cases, so initial treatment
should be conservative.
Corticosteroid injections can be an
effective treatment of trigger finger; this
and other appropriate non-invasive
interventions e.g. splinting12 should
precede consideration of surgery.
12
Peters-Veluthamaningal C, van der Windt DAWM, Winters JC, Meyboom- de Jong B. Corticosteroid injection for trigger finger in adults. Cochrane Database of Systematic
Reviews 2009, Issue 1. Art. No.: CD005617. DOI: 10.1002/14651858.CD005617.pub2.
Page 36
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for intervention
Additional information
Surgical treatment for
hallux valgus (bunions)
1. significant pain on walking not relieved by chronic standard
analgesia OR
2. deformity such that fitting adequate footwear is difficult OR
3. overlapping or underlapping of adjacent toe(s) OR
4. hammer toes OR
5. recurrent or chronic ulceration OR
6. bursitis or tendinitis of the first metatarsal head.
Before referral patients should be
informed that:



they will be in plaster for 6 weeks and
therefore unable to drive
it will take at least a further 2 months
to regain full functionality
the prognosis for treated and
untreated HV is very variable
There is very little good evidence on
which to assess either conservative or
operative treatments13.
13
Ferrari J, Higgins JP, Prior TD; Interventions for treating hallux valgus (abductovalgus) and bunions. Cochrane Database Syst Rev. 2004
http://www.ncbi.nlm.nih.gov/pubmed/14973960?dopt=Abstract
Page 37
Procedures of limited clinical value
Treatment
Criteria for intervention
Additional information
Knee washout for
osteoarthritis
This intervention is not routinely funded.
In accordance with NICE guidance (Aug
2007) on arthroscopic knee washout, with
or without debridement, for the treatment
of OA14 and the NICE clinical guideline on
OA (Feb 2008) on indications for which
arthroscopic lavage and debridement is
clinically and cost-effective15.
Referral for arthroscopic lavage and debridement should only be
considered in the few patients with knee osteoarthritis AND a clear
history of mechanical locking i.e. not gelling, 'giving way' or X-ray
evidence of loose bodies.
14
National Institute for Health and Clinical Excellence - Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis - Guidance issue date: 22
August 2007. http://www.nice.org.uk/IPG230
15
National Institute for Health & Clinical Excellence (NICE), Clinical guideline CG59 The care and management of patients with Osteoarthritis, February 2008
www.nice.org.uk/cg59.
Page 38
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for intervention
Additional information
Funding of dental implants will be considered for:
Predictors of implant failure are poor
bone quality, chronic periodontitis,
systemic diseases, smoking, unresolved
caries or infection, advanced age, implant
location and number; inappropriate
prosthesis design may also contribute to
implant failure16,17
Dental
Dental implants
In primary care i.e. General
Dental Practice (GDP), this
procedure would be funded,
through GDP contracts, by
NHS England.
16
17
1. major loss of tissue as a result of trauma or cancer surgery OR
2. significant congenital abnormalities (e.g. cleft lip & palate;
hypodontia), where the abnormality or its correction exclude use
of other prostheses OR
3. significant neuromuscular or other disorders (e.g. Parkinson‟s
Disease, Bell‟s palsy) which preclude use of conventional
dentures OR
4. some oral mucosal conditions, e.g. Sjogren‟s syndrome
5. severe jaw atrophy or alveolar bone resorption which preclude
use of conventional dentures AND
6. the patients underlying condition means that the procedure is
likely to be cost effective.
Implants in patients who have undergone
irradiation to the maxilla and/ or mandible
have a significantly higher failure rate.17
Patients who are over 60 years of age,
smoke, have a history of diabetes or
head and neck radiation, or are
postmenopausal and on hormone
replacement therapy experience
significantly increased implant failure
compared with healthy patients.17
Porter JA, von Fraunhofer JA. Gen Dent. 2005 Nov-Dec; 53(6):423-32
Moy PK, Medina D, Shetty V, Aghaloo TL. Int J Oral Maxillofacial Implants. 2005 Jul-Aug; 20(4):569-77
Page 39
Procedures of limited clinical value
Treatment
Criteria for intervention
Additional information
Wisdom tooth (third
molar) removal
In primary care i.e. General
Dental Practice (GDP), this
procedure would be funded,
through GDP contracts, by
NHS England.
Removal of third molar is only funded for:
See NICE guidance18.
1. unrestorable caries
2. non-treatable pulp and/ or periapical pathology
3. cellulitis
4. abscess and osteomyelitis
5. fracture of tooth
6. resorption of the tooth or adjacent teeth
7. disease of follicle including cyst / tumour
8. tooth impeding surgery/reconstructive jaw surgery
9. when a tooth is in the field of tumour resection/XRT
10. plaque formation and pericoronitis depending on severity and
frequency of episodes.
Other
Botox (botulinum toxin)
Botulinum A toxin is routinely funded only for:
1. Spasticity, hand and wrist disability associated with stroke,
blepharospasm, hemofacial spasm, spasmodic torticollis
2. Severe hyperhidrosis, overactive bladder syndrome
Botulinum B toxin is routinely funded only for:
3. spasmodic torticollis
4. as alternative to Botulinum toxin A in presence of antibodies to
Botulinum A.
18
http://www.nice.org.uk/nicemedia/pdf/wisdomteethguidance.pdf (accessed 8 February 2010)
Page 40
For palmar or plantar hyperhidrosis, other
procedures such as iontophoresis appear
to be more effective and have fewer side
effects and should be considered as
initial treatment.
Botox treatment needs to be repeated
after 6-9 months.
Procedures of limited clinical value (POLCV)
City & Hackney, Newham, Tower Hamlets, and Waltham Forest (WELC) CCGs
Treatment
Criteria for intervention
Additional information
Procedures for which access criteria have been agreed
Assisted conception
NEL CSU will support
CCGs to review these
criteria, taking into account
revised NICE Clinical
Guideline (expected
2013/14)
Unless or until WELC CCGs have confirmation that this service will
be commissioned by NHS England, access criteria for the couple
comprise:
Funding is available for eligible couples
for 3 locally defined cycles; each cycle
comprising an embryo transfer.
1. registration with local GP practice for at least 1 year
2. 2 years of unexplained infertility or one year of diagnosed subfertility within the current relationship
3. no living children within the current relationship and not more
than four between them from previous unions
4. neither partner will have previously undergone a sterilisation
procedure
5. couple have had less than three previous NHS-funded IVF
cycles leading to fresh embryo transfer
Neither donor sperm nor donor eggs are
NHS funded.
Because surgical sperm retrieval is not
covered within the existing contracts
within the reproductive service, this is not
currently funded.
Current access criteria for the female partner comprise:
6. age 23-39.9 years
7. BMI 19-30 kg/m2
Page 41
Procedures of limited clinical value
Index
abdominoplasty, 14
Double balloon enteroscopy, 24
Ketogenic diet for epilepsy, 23
Scars - treatment and revision 16
Acupuncture, 23
Dupuytren’s contracture, 36
labiaplasty 21
service level agreements
adenoidectomy, 28
earlobes repair of split, 21
lesions
alopecia, 16
ENT, 28
benign, 26
apronectomy, 14
Face lifts, 18
pigmented, 25
arm lift, 15
facial haemangiomas, 19
Liposuction, 15
skin excision, 15
Assisted conception, 41
Functional electrical stimulation
nose
skin lesions, 26
Bartholin’s cysts, 30
for footdrop, 24
surgery to reshape, 19
Blepharoplasty, 18
gall stones, 33
Occipital nerve stimulation
body contouring, 15
ganglia, 35
Botox, 40
gender reassignment, 23
Open MRI, 23
brachioplasty, 15
General surgery, 31
osteoarthritis, 38
Breast Procedures, 8-13
Grommet, 27
osteopathy, 23
brow lifts, 18
Hair - Epilation, transplantation,laser
electrolysis 17
otoplasty, 20
for intractable or cluster headache, 24
procedures outside of, 22
sinusitis, 29
surgical treatment of, 30
skin pigmentation
hyper or hypo, 20
Sympathectomy for severe
hyperhidrosis, 31
Tattoo Removal, 21
Tonsillectomy, 28
trigger finger, 36
bunions, 37
uterine fibroids
palmar, 31
hallux valgus, 37
buttock lift, 15
MRI guided ultrasound for, 23
Pigmented lesions, 25
headache
carpal tunnel syndrome, 35
varicocoele, 34
pinnaplasty, 20
varicose veins, 32
occipital nerve stimulation for, 23
Cholecystectomy, 33
plantar, 32
Herbal Medicines, 23
circumcision, 34
vascular lesions, 19
port wine stains, 19
Homeopathy, 22
Wisdom tooth, 40
reversal of sterilisation/vasectomy 22
Cosmetic surgery, 25
hyperhidrosis
Dental implants, 39
Rhinoplasty, 19
sympathectomy for, 31
Dilatation and curettage, 29
Rhytidectomy, 18
Hysterectomy, 30
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