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Version 2.10 November 2015 1. Low Priority Procedures (LPPs) Procedures with Restrictions (OPRs) and 2. Commissioning for Clinical Effectiveness 3. NICE Interventional Procedures Document Control Sheet CCG 1. Low Priority Procedures (LPPs) and Procedures with Restrictions (OPRs) 2. Commissioning for Clinical Effectiveness 3. NICE Interventional Procedures Coastal West Sussex CCG Version 2.9 Status Final Author Clinical Effectiveness Team Date Last Updated August 2015 Title History Version 2.6 2.7 2.8 2.9 2.10 Other Comments/details of change 21, 25, 28, 53, 68, 75, 81 and 96 4, 6, 10, 21, 25, 27, 28, 38, 39, 45, 47, 52, 64, 70, 75, 77, 89, 101 10 74 Some individual policies have been revised at different times in 2008, 2009, 2013, 2014 and 2015 Work is on-going by the CCG to review procedures that have not been reviewed. 2 Contents Acknowledgements 8 Introduction and Background 12 Rationale for Designating Procedures as Low Priority 12 Coastal West Sussex CCG Review Panel for Individual Funding Requests (IFR) 13 PART 1 - Low Priority Procedures & Other Procedures with Restrictions 1. Abdominoplasty / Apronectomy 2. Acne Scarring 3. Acupuncture 4. Advanced Mandibular Devices 5. Aromatherapy 6. Asymptomatic Impacted Third Molars 7. Basal Cell Papillomas 8. Blepharoplasty 9. Body Contouring 10. Botulinum Toxin Injections 11. Brachioplasty / Upper Arm Lift 12. Breast Augmentation 13. Breast Reduction 14. Brow Lift 15. Buttock Lift 16. Calf Implants 17. Capsule Endoscopy 18. Cataract Thresholds 19. Chalazia 20. Chemical Peels 21. Chinese Treatment 22. Chiropractic Therapy 23. Circumcision 24. Clinical Ecology 25. Co-careldopa for Advanced Parkinson’s Disease 26. Correction of Inverted Nipple 27. Dental Extraction of Non-Impacted Teeth 28. Dental Implants 29. Dermabrasion of Skin 30. Dilation and Curettage 31. Electrolysis 32. Excimir Laser Surgery for Short Sight 33. Excision of Redundant Skin or Fat 34. Eyelid Surgery 35. Face Lift 36. Female Sterilisation 37. Functional Electrical Stimulation 38. Gender Reassignment 39. Glucosamine 40. Grommets 41. Gynaecomastia 15 15 15 15 15 15 15 15 15 16 16 16 16 16 16 17 17 17 17 18 18 18 18 18 18 18 19 19 19 19 19 19 19 19 20 20 20 20 20 20 20 21 3 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. Hair Transplant / Hair Graft Herbal Remedies Hirsutism Treatment Homeopathy Hyperhidrosis Treatment Hyperbaric Oxygen Therapy for Wound Healing Hypnotherapy Labiaplasty Laser Therapy / Laser Treatment for Aesthetic Reasons / Tunable Dye Laser Limb Prosthesis Lingual Frenectomy Liposuction Massage Mastopexy Minor Irregularities of Aesthetic Significance Neck Lift Osteopathy Penile Implants Periapical Surgery/Apicectomy Pinnaplasty Plastic Operations on Umbilicus Private Treatment Available on the NHS Probiotics Ptosis of Eyelid Refashioning of Scar Reflexology Removal of Benign Skin Lesions Repair of Lobe of External Ear Residential Pain Management Programmes Retractile Penis Surgery Reversal of Vasectomy / Reversal of Sterilisation Rhinophyma Rhinoplasty / Septorhinoplasty Restorative Dental treatments in Secondary Care Skin Grafts for Scars Snoring Devices Submental Lipectomy Tattooing of Skin Tattoo Removal Terbinafine for Fungal Nail Infections Thigh Lift Thoracic Sympathectomy Tonsillectomies Traumatic Clefts due to Avulsion of Body Piercing Unplanned Admissions for Detoxification Upper Arm Reduction Varicose Veins Vertebroplasty Viral Warts Xanthelasma 21 21 22 22 22 22 22 22 22 22 22 22 23 23 23 23 23 23 23 23 23 23 24 24 24 24 24 25 25 26 26 26 26 26 26 26 27 27 27 27 27 27 27 27 28 28 28 28 29 29 PART 2 – Commissioning for Clinical Effectiveness 30 Orthopaedic Thresholds 92. Knee Arthroscopy 30 4 93. 94. 95. 96. 97. 98. Carpal Tunnel Syndrome Primary Knee Replacement Primary Hip Replacement Dupuytren’s Contracture Ganglion of the Wrist Trigger Finger 31 31 32 34 35 36 99. 100. 101. Hysterectomy for Dysfunctional Uterine Bleeding Female Genital Prolapse Orthodontics for Mild Malocclusions 36 37 38 PART 3 – NICE Interventional Procedures 39 102. 103. IPG357 - Percutaneous intradiscal laser ablation in the lumbar spine IPG297 - Combined bony and soft tissue reconstruction for hip joint stabilization in proximal focal femoral deficiency IPG162 - Mosaicplasty for knee cartilage defects IPG031 - Endoscopic laser foraminoplasty IPG083 - Percutaneous antiradical radiofrequency thermocoagulation for lower back 40 40 IPG333 - Therapeutic endoscopic division of epidural adhesions IPG141 - Automated percutaneous mechanical lumbar discectomy IPG341 - Prosthetic intervertebral disc replacement in the cervical spine IPG365 - Interspinous distraction procedures for spinal stenosis causing neurogenic claudication in the lumbar spine IPG173 - Percutaneous disc decompression using coblation for lower back pain IPG366 - Non-rigid stabilisation techniques for the treatment of low back pain IPG197 - Intramedullary distraction for lower limb lengthening IPG403 - Open femoro-acetabular surgery for hip impingement syndrome IPG332 - Surgical correction of hallux valgus using minimal access techniques IPG270 - Direct skeletal fixation of limb or digit prostheses using intraosseous transcutaneous implants IPG300 - Percutaneous endoscopic laser lumbar discectomy IPG303 - Percutaneous endoscopic laser cervical discectomy IPG305 - Sinus tarsi implant insertion for mobile flatfoot IPG311 - Extracorporeal shockwave therapy for refractory plantar fasciitis IPG312 - Extracorporeal shockwave therapy for refractory Achilles tendinopathy IPG313 - Extracorporeal shockwave therapy for refractory tennis elbow IPG321 - Lateral (including extreme, extra and direct lateral) interbody fusion in the lumbar spine IPG061 - Percutaneous endoscopic laser thoracic discectomy IPG363 - Minimally invasive two-incision surgery for total hip replacement IPG345 - Mini-incision surgery for total knee replacement IPG319 - Percutaneous intradiscal electrothermal therapy for low back pain IPG259 - Interstitial photodynamic therapy for malignant parotid tumours IPG042 - Cyanoacrylate instillation for occlusion of parotid sinuses IPG329 - Total prosthetic replacement of the temporomandibular joint IPG243 - Thoracoscopic aortopexy for severe primary tracheomalacia IPG318 - Bronchoscopic lung volume reduction with airway valves for advanced emphysema IPG307 - Intramuscular diaphragm stimulation for ventilator-dependent chronic 40 40 41 41 104. 105. 106. pain 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 123. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 5 40 40 40 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 41 134. 135. 136. 137. 138. 139. 141. 142. 143. 144. 145. 146. 147. 148. 149. 150. 151. 152. 153. 154. 155. 156. 157. 158. 159. 160. 161. 162. 163. 164. 165. 166. 167. 168. 169. 170. 171. 172. 173. respiratory failure due to neurological disease IPG090 - Intralesional photocoagulation of subcutaneous congenital vascular disorders IPG018 - Bone-anchored cystourethropexy (using data from In-Tac and Vesica as specified by SERNIP) IPG133 - Insertion of extraurethral (non-circumferential) retropubic adjustable compression devices for stress urinary incontinence in women IPG275 - Laparoscopic prostatectomy for benign prostatic obstruction IPG324 - Electrocautery cutting balloon treatment for pelviureteric junction obstruction IPG029 - Extracorporeal shockwave therapy for Peyronie's disease IPG036 - Radiofrequency volumetric tissue reduction of turbinate hypertrophy IPG124 - Radiofrequency ablation of the soft palate for snoring IPG428 - Extracorporeal membrane carbon dioxide removal IPG438 - Autologous blood injection for tendinopathy IPG059 - Subfascial endoscopic perforator vein surgery IPG037 - Transilluminated powered phlebectomy for varicose veins IPG389 - Carotid artery stent placement for carotid stenosis IPG229 - Laparoscopic repair of abdominal aortic aneurysm IPG440 - Ultrasound-guided foam sclerotherapy for varicose veins IPG219 - Lower limb deep vein valve reconstruction for chronic deep venous incompetence IPG041 - Partial left ventriculectomy (the Batista procedure) IPG294 - Percutaneous (non-thoracoscopic) epicardial catheter radiofrequency ablation for atrial fibrillation IPG128 - Totally endoscopic robotically assisted coronary artery bypass grafting IPG261 - Endoaortic balloon occlusion for cardiac surgery IPG025 - Laparo-endogastric surgery IPG055 - Endoscopic injection of bulking agents for gastro-oesophageal reflux disease IPG066 - Artificial anal sphincter implantation IPG350 - Photodynamic therapy for high-grade dysplasia in Barrett's oesophagus IPG103 - Gastroelectrical stimulation for gastroparesis IPG404 - Endoluminal gastroplication for gastro-oesophageal reflux disease IPG351 - Stapled transanal rectal resection for obstructed defaecation syndrome IPG200 - Photo-dynamic therapy for early oesophageal cancer IPG210 - Injectable bulking agents for faecal incontinence IPG392 - Stent insertion for bleeding oesophageal varices IPG274 - Autologous pancreatic islet cell transplantation for improved glycaemic control after pancreatectomy IPG276 - Transabdominal artificial bowel sphincter implantation for faecal incontinence IPG292 - Endoscopic radiofrequency ablation for gastro-oesophageal reflux disease IPG406 - Microwave ablation for the treatment of metastases in the liver IPG147 - Endoscopic axillary lymph node retrieval for breast cancer IPG257 - Allogeneic pancreatic islet cell transplantation for type 1 diabetes mellitus IPG308 - Image-guided radiofrequency biopsy of breast lesions IPG316 - Extracorporeal albumin dialysis for acute liver failure IPG401 - Selective internal radiation therapy for colorectal metastases in the liver 6 41 41 41 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 42 43 43 43 43 43 43 43 43 43 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. 194. 195. 196. 197. 198. 199. 200. 201. IPG201 - Preoperative high dose rate brachytherapy for rectal cancer IPG346 - Single-incision laparoscopic cholecystectomy IPG232 - Serial transverse enteroplasty procedure (STEP) for bowel lengthening in parenteral nutrition-dependent children IPG298 - Ex-vivo hepatic resection and reimplantation for liver cancer IPG251 - Liposuction for chronic lymphoedema IPG439 - Deep dermal injection of non-absorbable gel polymer for HIV-related facial lipoatrophy IPG373 - Selective dorsal rhizotomy for spasticity in cerebral palsy IPG252 - Laser-assisted cerebral vascular anastomosis without temporary arterial occlusion 43 43 43 IPG023 - Laparoscopic laser myomectomy IPG190 - Insertion of pleuro-amniotic shunt for fetal pleural effusion IPG062 - Falloposcopy with coaxial catheter IPG171 - Laparoscopic helium plasma coagulation for the treatment of endometriosis IPG202 - Fetal vesico-amniotic shunt for lower urinary tract outflow obstruction IPG030 - Magnetic resonance (MR) image-guided percutaneous laser ablation of uterine fibroids IPG205 - Fetal cystoscopy for diagnosis and treatment of lower urinary outflow tract obstruction IPG413 - Magnetic resonance image-guided transcutaneous focused ultrasound for uterine fibroids IPG339 - Macular translocation for wet age-related macular degeneration IPG058 - Transpupillary thermotherapy for age-related macular degeneration IPG069 - Insertion of hydrogel keratoprosthesis IPG334 - Arteriovenous crossing sheathotomy for branch retinal vein occlusion IPG209 - Implantation of accommodating intraocular lenses for cataract IPG216 - Tissue-cultured limbal stem cell allograft transplantation for regrowth of corneal epithelium IPG272 - Implantation of miniature lens systems for advanced age-related macular degeneration IPG299 - Tenotomy of horizontal eye muscles for nystagmus (with reattachment at their original insertions) IPG340 - Macular translocation with 360° retinotomy for wet age related macular degeneration IPG320 - Photochemical corneal collagen cross-linkage using riboflavin and ultraviolet A for keratoconus IPG247 - Thoracoscopic excision of mediastinal parathyroid tumours IPG408 - Arthroscopic femoro-acetabular surgery for hip impingement syndrome: Guidance 43 43 43 43 Appendix 1 – IFR Decision Making Process (Formerly PIN) 45 Appendix 2 – Ophthalmology Information Sheet 46 Appendix 3 – Coastal West Sussex CCG Varicose Vein Referral Guidelines 47 7 43 43 43 43 43 43 43 43 43 43 43 43 44 44 44 44 44 44 44 44 44 44 Acknowledgements for Low Priority Procedures & Other Procedures with Restrictions Thanks to the following individuals who contributed to and/or commented on the document or expressed their views in writing:Dr Clare Bashford Mr Ralph Beard Dr Amit Bhargava Ms Lauren Bosson Dr Richard Broome Mr Jeremy Collyer Dr Stephen Cox Dr Jean-Pierre Dias Mr Jim English Dr Paddy Feeny, Dr Andrew Foulkes Mr Peter Fox Dr Peter Hayward Dr David Howell Dr Elizabeth Jenkins Mr Peter Laws Ms Anna Lindsay Mr David Macpherson Mr Paul Mellings Dr Minesh Patel Mr Richard Pyper Dr Malcolm Ridley Mr Nick Saunders Dr Maurice Shipsey Dr Louise Sigfrid Dr Alison Smith Dr Farhang Tahzib Ms Lyndsay Trevethick Mr John Vincent-Townend Mr Alan Wilson Dr Charles Wood Family Planning Consultant Urologist Crawley Locality GP Hastings & Rother PCT Public Health SHO, West Sussex PCT Maxillo-Facial Consultant Mid-Sussex Locality Mid-Sussex Locality Consultant in Obstetrics and Gynaecology Adur Locality GP PEC Chair Consultant Ophthalmologist Consultant in Public Health, West Sussex PCT Horsham Locality GP Mid-Sussex Locality Consultant Vascular Surgeon Senior Public Health Programmes Manager, West Sussex PCT Consultant Maxillo Facial Surgeon Dentist Mid-Sussex Locality Consultant in Obstetrics and Gynaecology Western Sussex Locality GP Consultant ENT Surgeon Worthing Locality GP Public Health SHO, West Sussex PCT Adur Locality GP Director of Public Health, West Sussex PCT Priorities & Placement Panel, East Sussex Downs & Weald PCT Consultant Maxillo Facial Surgeon Consultant Maxillo Facial Surgeon PEC GP, Horsham Locality Pool of Currently trained West Sussex PCT Review Panel for “Patients with Individual Needs” (PIN) Members:Dr John Bull Mrs Joanna Cameron Dr Ann Corkery Ms Sarah Creamer Mrs Belinda Crockett Dr Ben Davies Dr Bobbie Farsides Ms Alison Gale Dr Peter Hayward Mrs Liz Horkin Mr Brian Hughes Dr Michele Lacey Dr Sarah Lock Mr Chris Mills Dr Lorena Rodriguez Ms Janet Scott Dr Farhang Tahzib Dr Guy Turner Mrs Sarah Valentine Dr Rodney Woodward-Court Consultant Physician Lay Member Consultant in Public Health Medicine PCT Director Lay Member Western Sussex Locality GP Independent Ethicist Finance, West Sussex PCT Consultant in Public Health Medicine PCT Director PCT Director Western Sussex Locality GP Western Sussex Locality GP Lay Member Western Locality GP Nurse Consultant Director of Public Health Consultant Anaesthetist Director of Sussex Acute Commissioning Worthing Locality GP 8 Dr Salvo Xerri Dr Nadia Ziyada Crawley Locality GP Horsham & Chanctonbury Locality GP Attendees at the West Sussex PCT forum for Service Improvement, Priorities and Clinical Effectiveness on 6th December 2006:Mr Philip Britton Mr Kevin Burgess Ms Sally Dando Ms Susan Dewar Mr Jeremy Collyer Dr Andrew Foulkes Mr Peter Fox Dr Peter Hayward Dr David Holwell Ms Wendy Langley Mr Paul Mellings Ms Maggie Middleton Mr Paul O’Toole Dr Nick Pegge Dr Malcolm Ridley Mr Mike Rymer Dr Alison Smith Dr Colin Spring Dr Farhang Tahzib Dr Matthew Taylor-Roberts Mr Alan Wilson Medical Director, Royal Western Sussex NHS Trust Queen Victoria Hospital PEC Allied Health Professional PEC Nurse Maxillo-Facial Consultant (apologies) PEC Chair Consultant Ophthalmologist Consultant in Public Health Medicine Horsham Locality GP PEC Pharmacist PEC Dentist Director of Development, Queen Victoria Hospital (apologies) Senior Negotiator, West Sussex PCT (apologies) Consultant Cardiologist Western Sussex Locality GP Medical Director, Worthing & Southlands Hospitals NHS Trust PEC Member & Adur Locality Lead GP Consultant Anaesthetist Director of Public Health, West Sussex PCT GP, Arun Locality Consultant Maxillo Facial Surgeon Acknowledgements for Commissioning for Clinical Effectiveness Thanks to the following individuals who contributed to and or commented on this initiative including SPACE & PEC members:Dr. Nick Adams Mr D Beattie Dr Amit Bhargava Dr John Bull Miss S. Burgert Mrs. Joana Cameron Ms. Denise Chaffer Miss Jo Clark Dr Ann Corkery Mr Neil Cripps Mr. David Dumigan Ms Sue Durrant Mr Jim English Ms Denise Foster Ms. Alison Gale Mr. David Goodger Mr. Hafez Dr S Hammans Mr Meredydd Harries Dr Peter Hayward Ms Alison Hempstead Mr Jonathan Hooker Mr Zak Ibrahim Dr. A. Karim Mr M Jolly Ms Anna Lindsay Dr. Sean McHale Consultant Chest Physician, WaSH Consultant General and Vascular Surgeon, RWST Practice Based Commissioning Lead for Crawley Consultant Physician, WaSH Consultant Hand & Orthopaedic Surgeon, RWST Lay member Head of Nursing, WaSH Consultant Maxillo Facial Surgery, RWST Associate Director of Public Health, WSPCT Consultant Surgeon, RWST Director of Finance, WaSH Chief Dietician, RWST Consultant in Obstetrics and Gynaecology,WaSH Emergency Services General Manager, RWST Assistant Director of Finance, WSPCT Area Director, South East Locality, WSPCT Consultant Vascular & General Surgeon Consultant Neurologist, RWST Consultant ENT Surgeon, WaSH & BSUH Associate Director of Public Health, WSPCT Area Director North East, WSPCT Consultant Obstetrician, RWST Consultant in Obstetrics and Gynaecology, RWST Consultant Dermatologist, RWST Consultant Obstetrician and Gynaecologist, RWST Snr Public Health Programmes Manager, WSPCT Consultant Anaethetist, RWST 9 Mr Tony Miles Ms Elaine Montgommery Mr Kush Narang Ms. Denise Newman Dr Minesh Patel Mrs Pat Radley Dr. D Ross Mr Michael Rymer Mr Nick Saunders Ms. Janice Scott Mr A Simons Mr J. Simpson Dr Alison Smith Dr P Tate Mr. L. Taylor Ms Tina Tomkins Mr Eddie Tuke Dr. Guy Turner Mrs. Sara Weech Clinical Director for Surgery, WaSH Midwifery, RWST Consultant in Orthopaedic Surgery, WaSH Midwifery, RWST Practice Based Commissioning Lead,Mid-Sussex Head of Primary Care Contracting, WSPCT Consultant Thoracic Physician, RWST Medical Director, WaSH Consultant ENT Surgeon, WaSH & BSUH Consultant Nurse, WaSH Consultant Obstetrician & Gynaecologist, RWST Consultant Colorectal Surgeon, RWST Practice Based Commissioning Lead Adur Consultant Thoracic Physician, RWST Consultant Orthopaedic Surgeon, RWST Area Director, Western Locality, WSPCT Head of Commissioning, RWST Consultant Anaethetist, RWST Director of Strategy, WSPCT 10 Agreed by the West Sussex Joint Forum for Service Improvement, Priorities and Clinical Effectiveness (SPACE) on 6 th December 2006. Ratified by the Professional Executive Committee (PEC) on 7 th December 2006. Considered by the Practice Based Commissioning Clinical Leads Group on the 12th July 2007. Approved by the West Sussex Joint Forum for Service Improvement, Priorities & Clinical Effectiveness (SPACE) on 27 th July 2007. Approved by the PCT’s Professional Executive Committee on 16th August 2007. Ratified by the West Sussex PCT Board on 27th September 2007. Noted by the West Sussex Health and Overview Scrutiny Committee on 22nd October 2007. Merged with Commissioning for Clinical Effectiveness Document September 2009. Individual policies have been revised at different times as necessary in 2008 & 2009, 2013, 2014 and 2015. Individual Policies in this document will continue to be reviewed as necessary in future. 11 Introduction and Background The agreed list will form part of the Service Level Agreements with the providers. There is no blanket ban on any of the procedures. There is an established CCG mechanism for dealing with individual cases / exceptions. This document applies to treatments outside of the primary care GMS contract This list does not apply to treatments which are part of a total package of reconstruction following major trauma or following surgery for cancer or where cancer is suspected, e.g. head and neck cancer surgery, mastectomy and breast reconstruction, burns and trauma post operative care. Exceptionality The IFR Panel shall determine, based upon the evidence provided to the panel, whether the patient has demonstrated exceptional clinical circumstances. The evidence to show that, for the individual patient, the proposed treatment is likely to be clinically effective may be part of the case that the patient’s clinical circumstances are asserted to be exceptional. However, in determining whether a patient is able to demonstrate exceptional clinical circumstances, the IFR Panel shall compare the patient to other patients with the same presenting medical condition at the same stage of progression. Whether a patient can demonstrate “exceptional clinical circumstances” depends on the precise clinical facts of each individual case and whether those can genuinely be described as exceptional. However, an IFR Panel may consider that a named patient who has clinical circumstances which, taken as a whole are outside the range of clinical circumstances presented by at least 95% of patients with the same medical condition at the same stage of progression as the named patient, could show that their clinical circumstances were sufficiently unusual that they could properly be described as being exceptional. The fact that a patient has exhausted all NHS treatment options available for a particular condition is unlikely, of itself, to be sufficient to demonstrate exceptional circumstances. Equally, the fact that the patient is refractory to existing treatments where a recognised proportion of patients with the same presenting medical condition at the same stage are, to a greater or lesser extent, refractory to existing treatments is unlikely, of itself, to be sufficient to demonstrate exceptional circumstances. Rationale for Designating Procedures as Low Priority Coastal West Sussex CCG has designated a number of procedures as low priority for NHS funding. The CCG is under significant financial pressure to provide funds for all treatments (or preventative measures) for all patients in Coastal West Sussex. The CCG does not have the resources to meet all of these demands. Therefore it has to make 12 difficult choices about which treatments/services represent the best use of its finite resources. The rationale for tightening restrictions on low priority procedures is as follows: 1. To allow funding to be concentrated on treatments which result in the most health gain and hence make the best use of limited resources for our population. 2. To offer better treatment access to patients with a high clinical priority by reducing referrals/admissions to the waiting lists. 3. In seeking to make appropriate use of limited resources the CCG has taken into account the following factors:a) The extent to which the problem in question is an illness, disease, injury or impairment. b) Whether the proposed treatment represents the appropriate clinical strategy to address the problem. c) Whether the service to address the problem can and should be subject to NHS funding. d) The evidence of clinical and cost effectiveness of the treatments. In this document is a list of procedures that Coastal West Sussex CCG has designated low priority for NHS funding and will not be routinely funded. This is not a blanket ban, the CCG recognises there will be exceptional, individual or clinical circumstances when funding for these treatments will be appropriate. In such cases, funding applications should be made to the Coastal West Sussex CCG Review Panel for Individual Funding Requests (IFR). Coastal West Sussex CCG will not pay for these procedures unless prior authorisation is obtained. This document also lists procedures which are funded by the CCG but where restrictions or a threshold for treatment applies. The Coastal West Sussex CCG Review Panel for Individual Funding Requests (IFR) The CCG has a very clear and explicit process for making decisions on treatments that are not routinely commissioned by the CCG. These include drugs, low priority procedures and treatments that have not yet been reviewed by NICE. The Review Panel will consider the following factors when making decisions: Resources Cost Effectiveness Scientific / Clinical Evidence of Effectiveness Guidance such as NICE Guidance and any other relevant guidance Specialist Advice where appropriate Alternative Treatments The Law Equity The document has been checked by Capsticks, the CCG solicitors. 13 All Review & Appeal Panel Members are trained in the following: How to evaluate clinical evidence Legal considerations including the Human Rights Legislation etc. CCG accountability for public funds SEC Framework The Review Panel terms of reference and appeal process guidance is available to clinicians and patients. Definitions and Clarifications Some LPPs mention procedures such as Acupuncture may be available as part of a defined a package of care - “What is a package of care?” Definition “A package of care is a co-ordinated approach to care involving a number of therapeutic measures. In this instance – these items are occasionally provided ancillary to other care as an adjuvant measure rather than as the main purpose of the attendance or admission.” What is a dental implant? Proposed “A dental implant is an artificial substitute/replacement for the root portion of natural tooth and is anchored into a pre-drilled socket in the jaw-bone to support a crown, bridge or secure a denture firmly in place”. 14 Part 1 - Low Priority Procedures and Other Procedures with Restrictions The CCG has considered evidence of clinical effectiveness and experience, information on current activity, resources, costs and provision in order to formulate the following recommendations 1. Abdominoplasty / Apronectomy This procedure is not routinely funded. 2. Acne Scarring Procedures for acne scarring are not routinely funded. 3. Acupuncture This procedure is not routinely funded by the CCG but may be available in some cases as part of a defined package of care. 4. Advanced Mandibular Devices/Snoring Devices These devices are not routinely funded. Commissioned through NHSE 5. Aromatherapy This procedure not routinely funded by the CCG. It is only available occasionally in hospices and hospitals as part of palliative care packages. 6. Asymptomatic Impacted Third Molars Surgical extraction of asymptomatic impacted third molars is not routinely funded save the circumstances recommended by NICE. All dental referrals are triaged through the Dental Referral Management Service. Referrals which have not been through the Dental Referral Management Service will not be funded. Commissioned through NHSE 7. Basal Cell Papillomas Please see “Removal of Benign Skin Lesions”. 8. Blepharoplasty This procedure is not routinely funded. Please note that the CCG supports the correction of ectropion and entropion. 15 9. Body Contouring This procedure is not routinely funded. 10. Botulinum Toxin Injections (Revised July 2015) The CCG supports the use of botulinum toxin injections for the treatment of the following conditions: blepharospasm, cervical dystonia, hemifacial spasm, neurogenic detrusor over activity and idiopathic detrusor over activity. For idiopathic detrusor over activity treatment will be funded for patients who meet be eligibility criteria below:Idiopathic detrusor overactivity Diagnosis of overactive bladder has been urodynamically confirmed Wet Failed Medical Management Intermittent self-catheterisation compliant A multi-disciplinary team has considered Botulinum toxin to be the most appropriate treatment Not funded for bladder pain Blepharospasm is an idiopathic condition, a focal dystonia. It can result in intermittent and closure of the lids resulting in functional blindness. Treatment is either botox chemo denervation or surgical myectomy. Hemi-facial spasm may be due to compression of the cranial nerve root and can also result in closure of the lids. Treatment is either chemo denervation or neurosurgical decompression. Botulinum toxin injections for other conditions will not be routinely funded. In exceptional cases, funding may be approved on an individual basis, via the agreed CCG mechanism. 11. Brachioplasty / Upper Arm Lift This procedure is not routinely funded the CCG. 12. Breast Augmentation Breast augmentation is not routinely funded by the CCG. It is only funded when it is required following surgery for cancer. The CCG will fund the removal of implants if they are causing pain or are a risk to the patient’s health but will not fund replacement of the implants. 13. Breast Reduction This procedure is not routinely funded. 14. Brow Lift 16 This procedure is not routinely funded by the CCG. 15. Buttock Lift This procedure is not routinely funded. 16. Calf Implants This procedure is not routinely funded. 17. Capsule Endoscopy This procedure is not routinely funded. 18. Cataracts Thresholds INTERIM POLICY September 2013 Coastal West Sussex Clinical Commissioning Group has reviewed its Cataract thresholds and has consequently altered the referral threshold, allowing for earlier referral of patients with Cataract. Coastal West Sussex Clinical Commissioning Group will fund Cataract surgery where patients meet the new criteria. Health Professionals are expected to take guidance from these Cataract thresholds into account when exercising their clinical judgement. These thresholds do not however override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient and in consultation with the patient and/or guardian/carer through a shared decision making process. The new criteria are as follows: First Eye Surgery Patients can only be referred where best corrected visual acuity as assessed by high-contrast testing (Snellen) as being: Best corrected binocular visual acuity of less than 6/9 (6/10 or worse) for drivers, OR Best corrected binocular visual acuity of 6/12 or worse for non-drivers, OR Reduced to 6/18 or worse in one eye irrespective of the acuity of the other eye, OR The patient wishes to/is required to drive and does not meet Driving and Licensing Authority (DVLA) eyesight requirements, OR The cataract is preventing the management of other co-existing eye conditions Second Eye Surgery Patients can only be referred for second eye surgery when their visual acuity meets the above criteria, OR 17 Difference in visual acuity between 1st and 2nd eye is so significant that it is preventing driving Exceptional Circumstances Coastal West Sussex Clinical Commissioning Group recognizes that there will be exceptional individual clinical circumstances when funding will be appropriate for patients who fall outside of the eligibility criteria. In such cases, funding applications should be made to the Coastal West Sussex review panel for Individual Funding Requests (IFR). Coastal West Sussex will not pay for these procedures unless prior authorization is obtained. Any suspicion of cataracts in children should be referred urgently. 19. Chalazia Chalazia (meibomian cysts) are benign, granulomatous lesions that will normally resolve within 6 months. Treatment consists of regular (four times daily) application of heatpacks. The CCG will fund excision of chalazia when all of the following criteria are met: The chalazia has been present for more than 6 months Where it is situated on the upper eyelid Where it is causing blurring of vision In common with all types of lesions, the CCG will fund removal where malignancy is suspected. These criteria also apply to eyelid papillomas 20. Chemical Peels This procedure is not routinely funded. 21. Chinese Treatments Not routinely funded. 22. Chiropractic Therapy This procedure is not routinely funded by the CCG but may be available in some cases as part of a defined package of care. 23. Circumcision The CCG will fund circumcision when the procedure is for: Patients with severe phimosis Severe recurrent balanitis Where cancer is suspected 24. Clinical ecology Clinical ecology procedures are not routinely funded by the CCG. 18 25. Co-careldopa intestinal gel (Duodopa ®) for the treatment of advanced Parkinson’s disease See Coastal West Sussex CCG area prescribing formulary 26. Correction of Inverted Nipple This procedure is not routinely funded. 27. Dental Extraction of Non-Impacted Teeth Extraction of non-impacted teeth will not be routinely funded in secondary care. . All dental referrals are triaged through the Dental Referral Management Service. Referrals which have not been through the Dental Referral Management Service will not be funded. Commissioned through NHSE 28. Dental Implants Dental implants are not routinely funded. All dental referrals are triaged through the Dental Referral Management Service. Referrals which have not been through the Dental Referral Management Service will not be funded. Commissioned 29. through NHSE Dermabrasion of Skin This procedure is not routinely funded. 30. Dilation and Curettage The Department of Health uses a basket of five procedures as an indicator or excess surgical activity. Dilation and curettage is one of these procedures. The CCG will fund dilation and curettage for diagnostic purposes and for evacuation of retained products of conception. The procedure will not be routinely funded for other reasons. 31. Electrolysis This procedure is not routinely funded. 32. Excimir Laser Surgery for Short Sight This procedure is not routinely funded. 33. Excision of Redundant Skin or Fat This procedure is not routinely funded. 19 34. Eyelid Surgery See Blepharoplasty 35. Face Lift This procedure is not routinely funded. 36. Female Sterilisation Sterilisation will not be available on non medical grounds unless the woman has had at least 12 months' trial using Mirena or Implanon and found it unsuitable. Exceptions to this policy include the following: Where sterilisation is to take place at the time of another procedure such as caesarean section. Where there is a clinical contraindication to the use of a Mirena/Implanon. Where there is an absolute clinical contraindication to pregnancy. These are:- young women (under 45 years of age) undergoing endometrial ablation for heavy periods - women with severe diabetes - women with severe heart disease Women should be informed that vasectomy carries a lower failure rate in terms of post-procedure pregnancies and that there is less risk related to the procedure. 37. Functional Electrical Stimulation This procedure is not routinely funded. 38. Gender Reassignment Commissioned through NHSE 39. Glucosamine See Coastal West Sussex CCG area prescribing formulary 40. Grommets The Department of Health uses a basket of five procedures as an indicator of excess surgical activity. Inserting grommets is one of these procedures. The policy statement on funding this procedure was developed with ENT consultant. There is only limited evidence that grommets are an effective treatment in children with otitis media with effusions. Therefore, they are not routinely 20 funded by the CCG. However the CCG will fund this procedure in children who are likely to benefit as follows:- Grommets for Children Grommets will not be routinely funded except for children who fulfil the criteria outlined below. These will be audited to ensure adherence to the criteria. If the trends and numbers go up significantly the policy will be revisited. Eligibility Criteria 1. Children with demonstrable conductive hearing loss for at least 6 months, in the presence of middle ear fluid and one of: Speech delay Difficulties at school related to hearing Behavioural difficulties related to hearing 2. Recurrent infections 3. Sensory neural hearing loss with supra-imposed either fluctuating or persistent conductive loss 4. Severe tympanic membrane retraction 5. A second disability such as Down’s Syndrome Grommets for Adults Grommets will be funded for adults who fulfil the criteria below. However, an application for funding must be submitted to the CCG for approval to ensure that these criteria are met. Eligibility criteria A middle ear effusion causing measured conductive hearing loss, persisting for at least 6 months and resistant to medical treatments. The patient must be experiencing disability due to deafness. The possible option of a hearing aid may be discussed, at the discretion of the clinician Persistent Eustachian tube dysfunction resulting in pain (e.g. flying) As one possible treatment for Meniere’s disease. Severe retraction of the tympanic membrane if the clinician feels this may be reversible and reversing it may help avoid erosion of the ossicular chain or the development of cholesteatoma. 41. Gynaecomastia Procedures to treat gynaecomastia in men are not routinely funded. 42. Hair Transplant / Hair Graft Hair transplant/grafting is not routinely funded. 21 43. Herbal Remedies Not routinely funded. See Coastal West Sussex CCG area prescribing formulary 44. Hirsuitism Treatment Laser treatment for hirsuitism is not routinely funded. 45. Homoeopathy Not routinely funded. See Coastal West Sussex CCG area prescribing formulary 46. Hyperhidrosis Treatment This procedure is not routinely funded. 47. Hyperbaric Oxygen Therapy for Wound Healing Commissioned through NHSE 48. Hypnotherapy There is little evidence that hypnotherapy is clinically effective. Therefore it is not routinely funded. 49. Labiaplasty This procedure is not routinely funded. 50. Laser Therapy / Laser Treatment for Aesthetic Reasons / Tunable Dye Laser The CCG will not routinely fund this procedure for cosmetic problems. 51. Limb prosthesis These are available on the NHS and will therefore not be funded privately. 52. Lingual Frenectomy This procedure is not routinely funded. Commissioned through NHSE 22 53. Liposuction The CCG will not routinely fund liposuction. However, liposuction may be used as part of other surgery ie. thinning of transplanted flap. 54. Massage This procedure is not routinely funded by the CCG The procedure is sometimes available in hospices as part of a palliative care package. 55. Mastopexy This procedure is not routinely funded. 56. Minor Irregularities of Aesthetic Significance The CCG does not routinely fund aesthetic procedures. 57. Neck Lift This procedure is not routinely funded. 58. Osteopathy This procedure is not routinely funded by the CCG but may be available in some cases as part of a defined package of care. 59. Penile Implants This procedure is not routinely funded. 60. Periapical Surgery/Apicectomy Periapical surgery will not be routinely funded except for those meeting the eligibility criteria. All dental referrals are triaged through the Dental Referral Management Service. Referrals which have not been through the Dental Referral Management Service will not be funded. Commissioned through NHSE 61. Pinnaplasty This procedure is not routinely funded. 62. Plastic Operations on Umbilicus Plastic operations on the umbilicus are not routinely funded. 23 63. Private Treatment Available on the NHS When clinicians retire from the NHS they may continue to practice privately. There are often patients who wish to continue seeing them, rather than see a new NHS clinician. The CCG will not routinely fund private consultations in these circumstances 64. Probiotics See Coastal West Sussex CCG area prescribing formulary 65. Ptosis of Eyelid Procedures to correct ptosis will only be funded in cases where formal visual field testing has demonstrated a visual field defect. The referral will not be accepted unless it is accompanied by documentary evidence of a visual field defect. 66. Refashioning of Scar This procedure is not routinely funded. 67. Reflexology This procedure is not routinely funded by the CCG. 68. Removal of Benign Skin Lesions Rationale Approach supported by national guidelines on cosmetic surgery. Limited evidence that surgery on these lesions for aesthetic reasons offers benefit to patients. Where there is no suspicion of malignancy or complications, benign skin lesions may be self-limiting, respond to conservative measures and have no long-term health consequences for patients. The policy acknowledges the potential for uncertainty of diagnosis, and, where there is concern over risk of malignancy, a secondary care opinion should be sought. There is a wide clinical consensus on the list of lesions included. Excision of benign skin lesions for purely aesthetic reasons will not be routinely funded in primary or secondary care except in exceptional circumstances via the appropriate CCG mechanism. This does not apply to lesions where there is suspicion of malignancy or serious complications or procedures covered by the minor surgery DES. The skin lesions covered in the list within the attached DES can be undertaken in both primary and secondary care. 24 The following are covered under the primary care DES minor surgery services and primary care Dermatology Services. Regular audits will be undertaken in relation to the procedures undertaken in primary care. Lipomata Lipomata are by definition not skin lesions, they are subcutaneous and their diagnosis depends on their not being attached to the skin. It is quite reasonable and clinically good practice to remove any subcutaneous lump if there is any doubt whatsoever about its diagnosis. Thus the DES will pay for removal of lipomata where there is any doubt about diagnosis or where they are symptomatic Sebaceous Cysts These are benign skin lesions in the sense of being non-malignant however they are not benign in the sense of not doing harm. They can become badly infected, smell badly, cause difficulty with rubbing with clothing. The DES will pay for removal of sebaceous cysts in any of the following circumstances: Cyst has become infected Cyst causes pain, discomfort, smell or is discharging Cyst is situated where it interferes with activities of normal daily living, such as hair combing, buttoning a collar, sitting in a chair, tightening a belt and similar Cyst is exceptionally large and a severe embarrassment to patient Chalazia Chalazia (meibomian cysts) are benign, granulomatous lesions that will normally resolve within 6 months. Treatment consists of regular (four times daily) application of heatpacks. The CCG will fund excision of chalazia when all of the following criteria are met: The chalazia has been present for more than 6 months Where it is situated on the upper eyelid Where it is causing blurring of vision In common with all types of lesions, the CCG will fund removal where malignancy is suspected. PLEASE NOTE: The CCG funds biopsy or excision of a lesion whenever there is concern that the lesion might have malignant potential. Such cases do not need approval by the CCG. The degree of suspicion of malignancy is a matter of clinical judgement by the referring clinician. 69. Repair of Lobe of External Ear This procedure is not routinely funded. 70. Residential Pain Management Programmes 25 Commissioned through NHSE 71. Retractile Penis Surgery This procedure is not routinely funded. 72. Reversal of Vasectomy / Reversal of Sterilisation The CCG will not routinely fund reversal of vasectomy and female sterilisation reversals. Patients who have a sterilisation procedure should be made aware that subsequent reversal of sterilisation will not normally be available on the NHS. 73. Rhinophyma Treatment for this condition is not routinely funded. 74. Rhinoplasty / Septorhinoplasty The CCG will not routinely fund these procedures. The CCG will only fund these procedures as a package of reconstructive surgery to restore function as part of a total package of surgery following major trauma [at the time that the reconstructive surgery takes place] or to repair cleft palate. 75. Restorative Dental Treatments in Secondary Care These procedures are not routinely funded. All dental referrals are triaged through the Dental Referral Management Service. Referrals which have not been through the Dental Referral Management Service will not be funded. Commissioned through NHSE 76. Skin Grafts for Scars This procedure is not routinely funded however the CCG will fund this treatment for burns and as part of reconstruction following major trauma. 77. Snoring Devices/Advanced Mandibular Devices These devices are not routinely funded These devices can now be bought over the counter 26 Commissioned through NHSE 78. Submental Lipectomy This procedure is not routinely funded. 79. Tattooing of Skin This procedure is not routinely funded. 80. Tattoo Removal This procedure is not routinely funded. 81. Terbinafine for Fungal Nail Infections See Coastal West Sussex CCG area prescribing formulary 82. Thigh Lift This procedure is not routinely funded. 83. Thoracic Sympathectomy This procedure is not routinely funded. 84. Tonsillectomies Tonsillectomy for Adults and Children CCGs will not routinely fund tonsillectomy except in children and adults who fulfil the criteria outlined below. Patients who fulfil the criteria below do not need to be considered by the Review Panel. However these will be audited to ensure adherence to the criteria. If the trends and numbers go up significantly the policy will be revisited. Eligibility Criteria Cases of suspected malignancy Sore throats must be due to tonsillitis and must be “disabling and prevent normal functioning”, the symptoms must have been present for at least a year and there must have been five or more episodes a year, two or more weeks absence from work/school/college/duties as a carer. Tonsillitis or quinsy requiring two or more hospital admissions Tonsillar enlargement causing upper airways obstruction. 27 85. Traumatic Clefts due to Avulsion of Body Piercing This procedure is not routinely funded. 86. Unplanned Admissions for Detoxification This procedure is not routinely funded. 87. Upper Arm Reduction This procedure is not routinely funded. 88. Varicose Veins The CCG will not routinely fund varicose veins except in patients who fulfil the eligibility criteria outlined below. Patients who meet the eligibility criteria do not need to be considered by the Individual Funding Requests (IFR) Panel. However these will be audited to ensure they only treat patients who meet the eligibility criteria. Trusts will not be paid for undertaking treatments that fall outside of the eligibility criteria. Eligibility Criteria 1. Venous Bleeding or above knee thrombophlebitis 2. Where patients have failed a trial of class I/II compression stockings for 4 months and any 2 of the following are present: Ulcer (active/healed) Lipodermatosclerosis Venous eczema For patients who do not meet the eligibility criteria and there are exceptional individual clinical circumstances an application for funding can be made to the Coastal West Sussex Individual Funding Requests (IFR) Panel. Check List for GP Referral: Confirmation that compression has been tried Document presence of ulceration Details of previous surgery/injections History of previous limb or pelvic trauma History of previous long illness with bed rest History of abnormal clotting/anticoagulation Family history of clotting disorders Drug history especially oral contraception or HRT See Appendix 3 for the Patient Referral Pathway 28 89. Vertebroplasty . 90. Viral Warts Viral warts are usually of aesthetic significance only and surgical removal is not routinely funded by the CCG. However, the CCG will fund removal of viral warts in patients who are immunocompromised. There are no restrictions on treatment of genital warts. 91. Xanthelasma This procedure is not routinely funded. 29 PART 2 – Commissioning for Clinical Effectiveness Orthopaedic Surgical Thresholds October 2013 Extensive research has been done to establish the areas on which we need to focus, and it has become clear that there is a need to tighten the thresholds around elective orthopaedic surgery to ensure we are providing the highest quality of care. Evidence tells us that we currently have the following issues: A higher than expected number of knee arthroscopies, a significant proportion of which appear to be diagnostic and could be avoided by using MRI A higher than expected number of carpal tunnel release operations and no robust enforcement of our current clinical threshold for this procedure A higher mean pre-op EQ-5D index score for hip and knee replacements (operating at an early stage in the disease process) A poor reported health gain for knee replacements (Patient Reported Health Outcomes) which is thought to be due to a lack of realistic expectations, operating too early in the disease process, and operating on patients who are at increased risk of poor outcomes due to severe or morbid obesity We are therefore introducing new surgical thresholds for: Knee arthroscopy Carpal Tunnel Release Primary Hip Replacement Primary Knee Replacement For each of these operations, IFR prior approval will be required unless the following clinical criteria are met. The IFR Panel can only consider exceptional clinical circumstances. Non-clinical factors are not taken into consideration. It is essential that the patient has had all options discussed with them and wishes to be considered for surgery prior to referral and this must be made clear in your referral letter. 94. Knee arthroscopy One of the following clinical indications must be present: 1. Mechanical symptoms of locking and/or instability PLUS clinical evidence of the need for: meniscal or articular cartilage resection or repair, ligament reconstruction, or removal of loose body at the same procedure; OR 2. Biopsy or synovectomy for inflammatory arthropathy, OR 3. Washout is needed for heamarthrosis or intra-articular infection OR 4. Further diagnosis is needed where MRI findings are equivocal or if MRI is contraindicated 30 It is highly unlikely a GP will be able to establish the clinical evidence of the need for meniscal, cartilage or ligament surgery. It is therefore expected that only MATT or T&O will be in a position to propose an arthroscopy. It is recommended that patients whom GPs suspect have such a need are referred to MATT for further assessment and investigation. 95. Carpal Tunnel Release Signs and symptoms of moderate/severe Carpal Tunnel Syndrome must present: - Paraesthesia and/or reversible numbness or pain - Persistent night awakening - Interference with ADL’s - ’weakness’ or ‘clumsiness’ AND if moderate symptoms, 3 months of appropriate conservative treatment has been trialed Mild Carpal Tunnel Syndrome (intermittent paraesthesia lasting, intermittent nocturnal waking, with or without pain) does not require surgical release. Moderate Carpal Tunnel Syndrome (constant paraesthesia but reversible numbness or pain, constant night waking, interference with ADL’s, “weakness” or “clumsiness”) resolves in the majority of cases with 3 months of conservative treatment (a neutral position wrist splint at night to ease night symptoms, and an optional single steroid injection to provide temporary relief (up to 1 month) whilst the condition resolves). Surgery is only indicated if after 3 months symptoms remain moderate/severe. Severe Carpal Tunnel Syndrome (constant numbness or pain, diminished sensation, wasting of thenar muscles, reduced power of thumb muscles) should be immediately referred to T&O for surgery. Full clinical guidelines with patient information leaflets and a severity scoring questionnaire can be found on the CWS website. 96. Primary Knee Replacement - New Oxford Score <20 - BMI < 40 - BMI < 35 unless patient has engaged with and completed a locally commissioned weight loss programme, or has achieved a 10% BMI reduction These criteria shall apply except: a) In patients whose pain is so severe and/or mobility so compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this threat OR b) In patients in whom the destruction of their joint is of such severity that 31 delaying surgical correction would increase the technical difficulty of the procedure Patients who have surgery on these exceptional grounds whose BMI is over 40 must be referred post-operatively to a locally commissioned weight loss programme 97. Primary Hip Replacement - Oxford Hip Score <20 - BMI < 40 - BMI < 35 unless patient has engaged with and completed a locally commissioned weight loss programme or has achieved a 10% BMI reduction These criteria shall apply except: a) in patients whose pain is so severe and/or mobility so compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this threat OR b) in patients in whom the destruction of their joint is of such severity that delaying surgical correction would increase the technical difficulty of the procedure Patients who have surgery on these exceptional grounds whose BMI is over 40 must be referred post-operatively to a locally commissioned weight loss programme GPs should only refer a patient whose BMI is 35-40 after either 10% weight loss achieved, or GP has received a written report from the weight loss service (eg Why Weight) confirming the patient's engagement from start to finish in one of their community weight loss programmes. Please note there is an old ‘Oxford Knee Score’ and a ‘New Oxford Score’. Both have the same 12 questions, but score them differently. You must use the New Oxford Score. The score cards you should use are available on the CWS CCG website. Frequently asked questions Why are we changing our surgical thresholds? We aren’t actually changing our knee arthroscopy and Carpal Tunnel Release thresholds. They are already Low Priority Procedures and have only been reworded for clarity. We previously had no thresholds of this kind for hip and knee replacements, and we believe this has led to poor outcomes for patients. Our new thresholds are based on strong clinical evidence, are fully supported by our local orthopaedic community, and are similar to those used elsewhere in the country. 32 This is absolutely not a rationing exercise to reduce costs, it is about ensuring we operate at the right time and with the lowest risks we can to improve outcomes. How am I, as a GP, supposed to assess for the clinical indications for knee arthroscopy? You aren’t! The knee arthroscopy thresholds are predominantly for the orthopaedic surgeons. We don’t expect you to be able to assess in primary care whether a knee arthroscopy is indicated or not - that usually requires diagnostics such as MRI and is therefore the role of MATT or T&O. You should refer patients with significant pain to MATT for further assessment and they will work them up, referring on for arthroscopy if needed. We have a difficult issue at the moment that many patients are being told by their GPs that they are being referred for arthroscopy when this is not yet indicated (and the letter sometimes even says ‘I believe this patient requires knee arthroscopy’). These expectations make it very hard for subsequent clinicians to then explain that this isn’t necessary and confuses the patients. In much the same way as patients with back pain don’t all need MRIs, patients with knee pain don’t all need arthroscopy, and we must help them understand this. What are Oxford Scores and why are we introducing them for hip and knee replacements? We have strong evidence that we are operating too early in the disease process so patients report gaining less from the operation than they expected and being disappointed with the results. The New Oxford Score and Oxford Hip Score are tools for assessing the severity of osteoarthritis of the knee and hip respectively, based upon a series of questions regarding functional ability. A score of 0-19 indicates severe disease, 20-29 moderate disease, 30-39 mild disease and 40 or above satisfactory joint function. The Oxford Scores will therefore ensure that patients are not operated upon in the mild to moderate stages of the disease, but are supported to wait until the disease is severe before resorting to having their own joint removed. They are a useful way of assessing the level of disability a patient is experiencing from their pain and should aid the important ‘shared decision making’ discussions around the different treatment options available (conservative and surgical). Please note there is an old ‘Oxford Knee Score’ and a ‘New Oxford Score’. Both have the same 12 questions, but score them differently. You must use the New Oxford Score for knees. Both score cards are embedded earlier and on the CWS CCG website. So every referral for hip or knee replacement now needs to include the patient’s BMI and Oxford score, and state they have had all options discussed and wish to be considered for surgery? Yes. If this information is missing, the referral will be rejected. It is the responsibility of the GP to collect this information if they are making the referral. Patients should not be referred to MATT purely for the completion of the Oxford Score Cards. 33 Why are we introducing BMI thresholds for hip and knee replacements? There is also strong and ever growing evidence that operating on patients who are morbidly obese (BMI >40) leads to more complications and a poorer outcome. Anaesthetic carries a greater risk at this level of obesity, and postop complications occur more frequently. It is much safer for patients to lose weight prior to surgery, unless their pain or mobility is so severe that they cannot wait. The evidence shows that severely obese patients (BMI >35) are also at increased risk from the anaesthetic and post-op complications, but they do achieve good outcomes eventually so the risk/benefit balance is more favourable. In these patients we need to ensure they fully understand the increased risk they are taking and we need to ensure they do all they can to minimize this risk by trying to lose weight prior to surgery. We acknowledge that there are some patients who are in such severe pain or have such mobility impairment that they are unable to function, (or who shouldn’t wait due to the condition of their joint) and for them delaying surgery to allow time for weight loss would not be reasonable. That is why there are the caveats that these patients can be excluded from the BMI criteria. Evidence is suggests however that they are unlikely to lose weight postoperatively and their outcomes will be less than ideal, therefore we are insisting that all patients with a BMI over 40 are referred post-op to a formal weight loss programme. Can patients who don’t meet these criteria apply for Individual Funding from the IFR panel (previously known as PIN Panel)? The Coastal West Sussex CCG Review Panel for Individual Funding Requests (IFR) will consider exceptional individual clinical circumstances for patients who fall outside of the eligibility criteria. Non-clinical factors are not taken into consideration. Applications should be made by the referrer who has all the necessary information, which in the vast majority of cases will be the GP. In some cases MATT may make the application if they are the referrer for surgery and are best informed to do so. Very rarely, an orthopaedic surgeon may make the application. If you feel your patient has exceptional clinical circumstances which justify making the case an exception to the policy you can make an application to the IFR Panel. Applications can be made using Form PF43 which is available on the CWS website. Details of where the form should be sent to are included at the bottom of the form. Alternatively the application can be emailed to [email protected]. 96. Dupuytren’s Contracture Rationale This intervention has been assessed by the South West Thames Public health Observatory as an effective procedure but with a close benefit/risk balance in mild cases. Evidence 34 Most patients with Dupuytren's disease do not need treatment and can be managed expectantly. Intervention is exclusively surgical and should be considered when function is impeded or deformity is disabling. In general, surgery should be performed on an affected PIP joint if the contracture is 25° or greater as such contractures are less likely to lead to a good outcome if allowed to progress. MCP joint contracture should be surgically corrected if they cause functional disability. Policy Statement Dupuytren’s contracture Surgery for Dupytren’s contracture is a low priority procedure and will not be routinely funded except via the appropriate CCG mechanism. The Panel will consider patients who have fulfilled the criteria below:Simple nodules in the palm are not an indication for surgery. Referral for Dupuytren’s contracture should only be made if defined criteria have been met: Referral indicated if: 1. Fixed flexion in one or more joints exceeding 25 degrees. 2. Young patients (under 45 years) with disease affecting 2 or more digits and fixed flexion exceeding 10 degrees. 97. Ganglion of the Wrist Rationale Asymptomatic ganglions are considered low priority for treatment and will not be funded. These should not normally be referred to secondary care. Ganglions arising at the level of the wrist rarely cause significant disability and will usually resolve. Policy Statement Ganglion of the wrist Surgery for ganglion of the wrist is a low priority procedure and will not be routinely funded by the CCG. Ganglion due to inflammatory or degenerative joint disease do not benefit from surgery but the underlying condition should be referred as appropriate. If ganglion suddenly increases in size and raises suspicion of an alternative diagnosis please refer. Neurological loss or weakness of the wrist and muscle wasting of the hand should be considered for referral. In the absence of the above conditions patients can be reassured and told to seek assistance if the situation changes. There is a reasonable chance that ganglia will disappear spontaneously and even if they persist they do not 35 cause adverse long term effects. Conservative management is largely a matter of reassurance. Sometimes support and rest to the wrist can cause ganglions to disappear. Rest and splinting can also cause symptomatic ganglions to resolve. Revised SS 98. December 2013. Trigger Finger Rationale Trigger finger causes snapping of the fingers as they are extended from a fully flexed posture and is sometimes associated with a tender nodule in flexor tendon at base of finger or thumb. Policy Statement Trigger Finger Surgery for trigger finger is a low priority procedure and will not be routinely funded, except via the appropriate CCG mechanism. The Panel will consider patients who fulfil the criteria below: Where the patient has failed to respond to conservative measures. Up to 2 hydrocortisone injections into the tendon sheath will often settle early cases. OR Where the patient has a fixed deformity that cannot be corrected. 99. Hysterectomy for Dysfunctional Uterine Bleeding Rationale The Mirena® device has been shown to be effective in the treatment of heavy menstrual bleeding. The levonorgestrel intrauterine system is considerably cheaper than performing a hysterectomy, even if required for many years. A number of effective conservative treatments are available as second line treatment after failure of Mirena or where it is contra-indicated. Evidence NICE published Clinical Guidelines on heavy menstrual bleeding in January 2007. Regarding hysterectomy for heavy menstrual bleeding this guidance states: Hysterectomy should not be used as a first-line treatment solely for heavy menstrual bleeding. Hysterectomy should be considered only when: 36 other treatment options have failed, are contraindicated or are declined by the woman there is a wish for amenorrhoea the woman no longer wishes to retain her uterus and fertility. A Cochrane systemic review concluded that levonorgestrel intrauterine system/Mirena coil improved the quality of life of women with menorrhagia as effectively as hysterectomy. Policy Statement Hysterectomy for Dysfunctional Uterine Bleeding Prior to referral to secondary care treatment with non-steroidal antiinflammatory agents and/or tranexamic acid should have been tried unless contraindicated. Coastal West Sussex CCG will not routinely fund hysterectomy for dysfunctional uterine bleeding except where: There has been a prior trial with a levonorgestrel intrauterine system (Mirena®) (unless contraindicated) and/or endometrial resection/ablation which has not successfully relieved symptoms. Contraindications to the levonorgestrel intrauterine system are: Severe anaemia, unresponsive to transfusion or other treatment, whilst a levonorgestrel intrauterine system trial is in progress. Distorted or small uterine cavity (with proven ultrasound measurements). Genital malignancy Active trophoblastic disease Pelvic inflammatory disease Established or marked immunosuppression Submucous fibroid 100. Female Genital Prolapse Rationale Prolapse is often asymptomatic and an incidental finding, and clinical examination may not necessarily correlate with symptoms Surgical intervention has been assessed as effective but with a close benefit/risk balance in mild cases. Evidence Prevention Few large prospective trials have assessed the prevention of prolapse: The role of obstetric risk factors is unclear - reduced duration of the second stage of labour, decreased use of instrumental deliveries, and episiotomies may help prevent prolapse in the long term Treatment of conditions that increase intra-abdominal pressure such as constipation, obstructive airway disease, chronic cough, and obesity are primary and secondary prevention strategies 37 The role of hormone replacement therapy in preventing prolapse is uncertain Pelvic floor exercises after childbirth may help, though this has not been proved Conservative treatment should always be offered before referral to hospital. Pelvic floor exercises Pelvic floor exercises may limit the progression of mild prolapse and alleviate mild prolapse symptoms such as low backache and pelvic pressure. However, they are not useful if the prolapse extends to or beyond the vaginal introitus. Policy Statement Female Genital Prolapse West Sussex CCG will not normally fund surgery for asymptomatic or mild pelvic organ prolapse. The indications for surgery are: Failure of pessary1 Prolapse combined with urethral sphincter incompetence or faecal incontinence – referral to a specialist urogynaecologist should be considered. Reassurance, self help information such as weight loss and avoidance of constipation should be provided together with physiotherapy for pelvic floor muscle training or trial of ring pessary where symptoms are mild. 101. Orthodontics for Mild Malocclusions (IOTN1,2,3) in Secondary Care. All dental referrals are triaged through the Dental Referral Management Service. Referrals which have not been through the Dental Referral Management Service will not be funded Orthodontic treatment in secondary care will only be funded for patients who score 4 or 5 on the Index of Orthodontic Treatment Need (IOTN). Commissioned through NHSE 38 PART 3 – NICE Interventional Procedures 1. Introduction The CCG is under significant pressure to provide funding for a range of treatments or preventative measures for all patients in Coastal West Sussex. The CCG does not have the resources to meet all of these demands; therefore it has to make difficult choices about which treatments/services represent the best use of its finite resources. The CCG has to take into account the evidence of clinical effectiveness and cost effectiveness when making these choices. Due to the economic situation resources for public sector services will continue to be severely constrained for the foreseeable future. Even the most generous of the funding programmes proposed for the NHS would allow for only a 1% growth in real terms. This is unprecedented in the recent history of the NHS. The forecast increase in the numbers of older people in Coastal West Sussex along with the increasing cost of pharmaceuticals and the continuous improvements in medical technology mean that resources will be under enormous strain and to avoid cuts in vital services productivity improvements and cost efficiencies are vital. In reviewing the scope of the CCG’s current expenditure it is clear that there is a rising demand for some services where there is only weak evidence that the benefit derived from the service justifies the cost. Coastal West Sussex CCG will not commission these procedures and will prioritise others alongside existing priorities. The effect of not commissioning some of the procedures will be to allow funding to be directed at treatments which will result in the greatest health gain. This makes the best use of finite resources and enables the CCG to offer better treatment access to those patients who are a higher clinical priority. 2. Treatments that are the subject of a NICE Interventional Procedure Guidance (IPG) NICE issues Interventional Procedure Guidance (IPGs) with the aim of protecting the safety of patients and supporting the NHS in the process of introducing new procedures. The IPGs are not covered by the Secretary of States directions to NHS organisations to fund the implementation of NICE recommendations within a given timescale because this direction relates only to NICE Technology Appraisal Guidance (TAGs). NICE Technology Appraisal Guidance (TAGs) are mandatory for CCGs to fund and Coastal West Sussex CCG funds all NICE TAGs. Interventional Procedure Guidance makes recommendations on the safety of the procedure and how well it works. The guidance does not recommend whether the NHS should fund a procedure; or not and these decisions are therefore for the Primary Care Trusts. 39 Coastal West Sussex CCG recognises that it is not within the remit of the NICE IPG Programme to evaluate the cost-effectiveness of interventional procedures or to advise the NHS whether interventional procedures should be funded. 3. Specific commissioning categories of IPG 3.1 position with respect to different Special Arrangements Coastal West Sussex CCG will not routinely fund health care interventions that are subject to a NICE IPG where the IPG states: Current evidence on safety is inadequate Current evidence on efficacy is inadequate Evidence of safety and efficacy is on small numbers of patients and of limited quality. No major safety concerns. But efficacy has not been shown. Evidence is limited to a small number of patients. Good short term efficacy but little evidence of long term efficacy There is adequate evidence of safety and efficacy but the technical demands are such that is should not be used without special arrangements. Evidence for short term efficacy is limited and long term outcomes are uncertain. 3.2 Research Only Coastal West Sussex CCG will not routinely fund health care interventions that the NICE IPG programme has recommended should only be undertaken in the context of research. Clinicians wishing to undertake such procedures should ensure they fulfil the normal requirements for undertaking research. Where there is a possibility that there may be impacts on NHS funded care following the cessation of the trial, or a patient’s completion of a trial, clinicians are strongly encouraged to discuss this with Coastal West Sussex CCG at the earliest opportunity. Such requests will be considered within the context of the Coastal West Sussex CCG Policy on Trial Exit 3.3 Do not use Coastal West Sussex CCG will not fund health care interventions where a NICE IPG recommends that the intervention should not be used in the NHS No. Title Issue Date NICE Conclusions Specialty Sep-10 Current evidence on safety and efficacy is inadequate. Orthopaedic Apr-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 103. IPG357 Percutaneous intradiscal laser ablation in the lumbar spine IPG297Combined bony and soft tissue reconstruction for hip joint stabilisation in proximal focal femoral deficiency (PFFD) 104. IPG162 Mosaicplasty for knee cartilage defects Mar-06 Current evidence on safety is adequate. Orthopaedic 105. IPG031 Endoscopic laser foraminoplasty Dec-03 Current evidence on safety and efficacy is inadequate. Orthopaedic 106. IPG083 Percutaneous intradiscal radiofrequency thermocoagulation for lower back pain Aug-04 Current evidence on safety and efficacy is inadequate. Orthopaedic 102. 40 107. IPG333 (replaces IPG088) Therapeutic endoscopic division of epidural adhesions Sep-04 Current evidence on safety and efficacy is inadequate. Orthopaedic 108. IPG141 Automated lumbar discectomy Nov-05 Current evidence on safety is adequate. Orthopaedic May-10 Current evidence on safety is adequate. Orthopaedic Nov-10 Current evidence on safety is adequate. Orthopaedic May-06 Current evidence on safety is adequate. Orthopaedic Orthopaedic percutaneous mechanical 110. IPG341 Prosthetic intervertebral disc replacement in the cervical spine IPG365 Interspinous distraction procedures for spinal stenosis causing neurogenic claudication in the lumbar spine 111. IPG173 Percutaneous disc decompression using coblation for lower back pain 112. IPG366 Non-rigid stabilisation techniques for the treatment of low back pain Nov-10 Current evidence on safety is inadequate. 113. IPG197 Intramedullary distraction for lower limb lengthening Dec-06 Current evidence on safety and efficacy is inadequate. Orthopaedic 114. IPG403 Open femoro-acetabular surgery for hip impingement syndrome Jul-11 Current evidence on safety and efficacy is inadequate. Orthopaedic 115. IPG332 Surgical correction of hallux valgus using minimal access techniques Feb-10 Current evidence on safety and efficacy is inadequate. Orthopaedic 116. IPG270 Direct skeletal fixation of limb or digit prostheses using intraosseous transcutaneous implants Jul-08 Current evidence on safety and efficacy is inadequate. Orthopaedic 117. IPG300 Percutaneous endoscopic laser lumbar discectomy May-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 118. IPG303 Percutaneous endoscopic laser cervical discectomy Jun-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 119. IPG305 Sinus tarsi implant insertion for mobile flatfoot Jul-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 120. IPG311Extracorporeal shockwave refractory plantar fasciitis Aug-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 121. IPG312 Extracorporeal shockwave therapy for refractory Achilles tendinopathy Aug-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 122. IPG313 Extracorporeal shockwave therapy for refractory tennis elbow Aug-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 123. IPG321 Lateral (including extreme, extra and direct lateral) interbody fusion in the lumbar spine Nov-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 124. IPG061Percutaneous endoscopic discectomy Jun-04 Current evidence on safety and efficacy is inadequate. Orthopaedic 125. IPG363 Minimally invasive two-incision surgery for total hip replacement Oct-10 Current evidence on safety and efficacy is inadequate. Orthopaedic 126. IPG345 Mini-incision replacement May-10 Current evidence on safety and efficacy is inadequate. Orthopaedic 127. IPG319 Percutaneous intradiscal electrothermal therapy for low back pain Nov-09 Current evidence on safety and efficacy is inadequate. Orthopaedic 128. IPG259 Interstitial photodynamic malignant parotid tumours Apr-08 Current evidence on safety and efficacy is inadequate. Maxillofacial 129. IPG042 Cyanoacrylate instillation for occlusion of parotid sinuses Feb-04 Current evidence on safety and efficacy is inadequate. Maxillofacial 130. IPG329Total prosthetic temporomandibular joint Dec-09 Current evidence on safety and efficacy is inadequate. Maxillofacial 131. IPG243Thoracoscopic aortopexy for severe primary tracheomalacia Dec-07 Current evidence on safety and efficacy is inadequate. Respiratory 132. IPG318 Bronchoscopic lung volume reduction with airway valves for advanced emphysema Nov-09 Current evidence on safety and efficacy is inadequate. Respiratory 133. IPG307 Intramuscular diaphragm stimulation for ventilator-dependent chronic respiratory failure due to neurological disease Jul-09 Current evidence on safety and efficacy is inadequate. Respiratory 134. IPG090 Intralesional photocoagulation subcutaneous congenital vascular disorders Sep-04 Current evidence on safety and efficacy is inadequate. Dermatology 109. surgery therapy for laser thoracic for total therapy replacement of knee for the of 41 135. IPG018 Bone-anchored cystourethropexy (using data from In-Tac and Vesica as specified by SERNIP) Nov-03 Current evidence on safety and efficacy is inadequate. Urology 136. IPG133 Insertion of extraurethral (noncircumferential) retropubic adjustable compression devices for stress urinary incontinence in women Jul-05 Current evidence on safety and efficacy is inadequate. Urology 137. IPG275 Laparoscopic prostatectomy for benign prostatic obstruction Nov-08 Current evidence on safety and efficacy is inadequate. Urology 138. IPG324 Electrocautery cutting balloon treatment for pelviureteric junction obstruction Dec-09 Current evidence on safety and efficacy is inadequate. Urology 139. IPG029 Extracorporeal shockwave therapy for Peyronie's disease Dec-03 Current evidence on safety is adequate. Current evidence on efficacy is inadequate. Urology 140. IPG224 Insertion of extraurethral (noncircumferential) retropubic adjustable compression devices for stress urinary incontinence in men Jul-07 Current evidence on safety and efficacy is inadequate. Urology 141. IPG036 Radiofrequency volumetric tissue reduction of turbinate hypertrophy Jan-04 Current evidence on safety and efficacy is inadequate. ENT 142. IPG124 Radiofrequency ablation of the soft palate for snoring May-05 Current evidence on safety is adequate. Current evidence on efficacy is inadequate. ENT 143. IPG428 Arteriovenous extracorporeal membrane carbon dioxide removal Jun-12 Current evidence on safety and efficacy is inadequate. ITU 144. IPG438 Autologous blood injection for tendinopathy Jan-13 Current evidence on safety and efficacy is inadequate. Rheumatology 145. IPG059 Subfascial surgery Jun-04 Current evidence on safety and efficacy is inadequate. Vascular Surgery 146. IPG037 Transilluminated powered phlebectomy for varicose veins Jan-04 Current evidence on safety and efficacy is inadequate. Vascular Surgery 147. IPG389 Carotid artery stent placement for carotid stenosis Apr-11 Current evidence on safety and efficacy is inadequate. Vascular Surgery 148. IPG229 Laparoscopic repair of abdominal aortic aneurysm Aug-07 Current evidence on safety and efficacy is inadequate. Vascular Surgery 149. IPG440 Ultrasound-guided foam sclerotherapy for varicose veins Feb-13 Current evidence on safety and efficacy is inadequate. Vascular Surgery 150. IPG219 Lower limb deep vein valve reconstruction for chronic deep venous incompetence May-07 Current evidence on safety and efficacy is inadequate. Vascular Surgery 151. IPG041Partial left procedure) Feb-04 Current evidence on safety and efficacy is inadequate. Cardiology 152. IPG294 Percutaneous (non-thoracoscopic) epicardial catheter radiofrequency ablation for atrial fibrillation Mar-09 Current evidence on safety and efficacy is inadequate. Cardiology 153. IPG128 Totally endoscopic robotically assisted coronary artery bypass grafting Jun-05 Current evidence on safety and efficacy is inadequate. Cardiology 154. IPG261Endoaortic balloon occlusion for cardiac surgery May-08 Current evidence on safety and efficiacy is adequate. Cardiology Dec-03 Current evidence on safety and efficacy is inadequate. Gastroenterology Apr-04 Current evidence on safety and efficacy is inadequate. Gastroenterology Gastroenterology endoscopic perforator vein ventriculectomy (the Batista 155. IPG025 Laparo-endogastric surgery 156. IPG055 Endoscopic injection of bulking agents for gastro-oesophageal reflux disease 157. IPG066 Artificial anal sphincter implantation Jun-04 Current evidence on safety and efficacy is inadequate. 158. IPG350 Photodynamic therapy dysplasia in Barrett's oesophagus Jun-10 Current evidence on the safety is adequate. Gastroenterology 159. IPG103 Gastroelectrical gastroparesis Dec-04 Current evidence on safety and efficacy is inadequate. Gastroenterology 160. IPG404 Endoluminal gastroplication for gastrooesophageal reflux disease Jul-11 Current evidence on safety and efficacy is inadequate. Gastroenterology 161. IPG351 Stapled transanal rectal resection for obstructed defaecation syndrome Jun-10 Current evidence on safety and efficacy is inadequate. Gastroenterology 162. IPG200 Photo-dynamic oesophageal cancer Dec-06 Current evidence on safety and efficacy is inadequate. Gastroenterology for high-grade stimulation therapy for for early 42 163. IPG210 Injectable incontinence 164. bulking agents for faecal Feb-07 Current evidence on safety and efficacy is inadequate. Gastroenterology IPG392 Stent insertion for bleeding oesophageal varices Apr-11 Current evidence on safety and efficacy is inadequate. Gastroenterology 165. IPG274Autologous pancreatic islet cell transplantation for improved glycaemic control after pancreatectomy Sep-08 Current evidence on safety and efficacy is inadequate. Gastroenterology 166. IPG276 Transabdominal artificial bowel sphincter implantation for faecal incontinence Nov-08 Current evidence on safety and efficacy is inadequate. Gastroenterology 167. IPG292 Endoscopic radiofrequency ablation for gastro-oesophageal reflux disease Mar-09 Current evidence on safety and efficacy is inadequate. Gastroenterology 168. IPG406 Microwave ablation for the treatment of metastases in the liver Aug-11 Current evidence on safety and efficacy is inadequate. Gastroenterology 169. IPG147 Endoscopic axillary lymph node retrieval for breast cancer Dec-05 Current evidence on safety and efficacy is inadequate. Gastroenterology 170. IPG257 Allogeneic pancreatic islet transplantation for type 1 diabetes mellitus Apr-08 Current evidence on safety and efficacy is inadequate. Gastroenterology 171. IPG308 Image-guided radiofrequency biopsy of breast lesions Jul-09 Current evidence on safety and efficacy is inadequate. Gastroenterology 172. IPG316 Extracorporeal albumin dialysis for acute liver failure Sep-09 Current evidence on safety and efficacy is inadequate. Gastroenterology 173. IPG401 Selective internal radiation therapy for colorectal metastases in the liver Jul-11 Current evidence on safety is adequate. Gastroenterology 174. IPG201 Preoperative high dose rate brachytherapy for rectal cancer Dec-06 Current evidence on safety is adequate. Gastroenterology 175. IPG346Single-incision cholecystectomy May 21010 Current evidence on safety and efficiacy is inadequate. Gastroenterology 176. IPG232 Serial transverse enteroplasty procedure (STEP) for bowel lengthening in parenteral nutritiondependent children Sep-07 Current evidence on safety is adequate. Gastroenterology 177. IPG298 Ex-vivo hepatic resection and reimplantation for liver cancer Apr-09 Current evidence on safety and efficacy is inadequate. Gastroenterology 178. IPG251 Liposuction for chronic lymphoedema Feb-08 Current evidence on safety and efficacy is inadequate. Gastroenterology 179. IPG439 Deep dermal injection of non-absorbable gel polymer for HIV-related facial lipoatrophy Jan-13 Current evidence on safety and efficacy is inadequate. Gastroenterology 180. IPG373 Selective dorsal rhizotomy for spasticity in cerebral palsy Dec-10 Current evidence on safety is adequate. Neurosurgery 181. IPG252 Laser-assisted cerebral vascular anastomosis without temporary arterial occlusion Feb-08 Current evidence on safety and efficacy is inadequate. Neurosurgery 182. IPG023 Laparoscopic laser myomectomy Nov-03 Current evidence on safety and efficacy is inadequate. O&G 183. IPG190 Insertion of pleuro-amniotic shunt for fetal pleural effusion Sep-06 Current evidence on safety and efficacy is inadequate. O&G 184. IPG062 Falloposcopy with coaxial catheter Jun-04 Current evidence on safety and efficacy is inadequate. O&G 185. IPG171 Laparoscopic helium plasma coagulation for the treatment of endometriosis May-06 Current evidence on safety and efficacy is inadequate. O&G 186. IPG202 Fetal vesico-amniotic shunt for lower urinary tract outflow obstruction Dec-06 Current evidence on safety and efficacy is inadequate. O&G 187. IPG030 Magnetic resonance (MR) image-guided percutaneous laser ablation of uterine fibroids Dec-03 Current evidence on safety and efficacy is inadequate. O&G 188. IPG205 Fetal cystoscopy for diagnosis and treatment of lower urinary outflow tract obstruction Jan-07 Current evidence on safety and efficacy is inadequate. O&G 189. IPG413 Magnetic resonance image-guided transcutaneous focused ultrasound for uterine fibroids Nov-11 Current evidence on safety and efficacy is inadequate. O&G cell laparoscopic 43 - 190. IPG339 Macular translocation for wet age-related macular degeneration May-10 Current evidence on safety and efficacy is inadequate. Ophthalmology 191. IPG058 Transpupillary thermotherapy for agerelated macular degeneration Jun-04 Current evidence on safety and efficacy is inadequate. Ophthalmology 192. IPG069 Insertion of hydrogel keratoprosthesis Jun-04 Current evidence on safety and efficacy is inadequate. Ophthalmology 193. IPG334 Arteriovenous crossing sheathotomy for branch retinal vein occlusion Mar-10 Current evidence on safety and efficacy is inadequate. Ophthalmology 194. IPG209 Implantation of accommodating intraocular lenses for cataract Feb-07 Current evidence on safety is adequate. Ophthalmology 195. IPG216 Tissue-cultured limbal stem cell allograft transplantation for regrowth of corneal epithelium Apr-07 Current evidence on safety and efficacy is inadequate. Ophthalmology 196. IPG272 Implantation of miniature lens systems for advanced age-related macular degeneration Aug-08 Current evidence on safety and efficacy is inadequate. Ophthalmology 197. IPG299 Tenotomy of horizontal eye muscles for nystagmus (with reattachment at their original insertions) May-09 Current evidence on safety and efficacy is inadequate. Ophthalmology 198. IPG340 Macular translocation with 360° retinotomy for wet age related macular degeneration May-10 Current evidence on safety and efficacy is inadequate. Ophthalmology 199. IPG320 Photochemical corneal collagen crosslinkage using riboflavin and ultraviolet A for keratoconus Nov-09 Current evidence on safety and efficacy is inadequate. Ophthalmology 200. IPG247 Thoracoscopic excision of mediastinal parathyroid tumours Dec-07 Current evidence on safety and efficacy is inadequate. Endocrinology 201. IPG408 Arthroscopic femoro-acetabular surgery for hip impingement syndrome: Guidance Sep-11 Current evidence on safety and efficacy is inadequate. Ortho Note IPG 001 - Uterine Artery Embolisation for Fibroids was revised by NICE in 2010 and will be discussed by SPACE. 44 Appendix 1 - IFR Decision Making Process (Formerly PIN) Request from General Practitioner / other practitioners Request from Consultant Proposal for treatment Case presented addressing questions on form PF4 or Drug questionnaire or letter outlining why a case should be treated as an exception to the Clinical Policy/Low Priority Procedures etc. Clinical Evidence Review & Position of the Clinical Networks Independent Expert Specialist Input for all Specialities as appropriate IFR Panel Review Panel Membership: Clinicians (GPs and hospital consultants) Dentist Consultant in Public Health Medicine CCG Finance/Commissioners Lay Person/Member (s) Public Health Specialist who prepares case papers and Evidence Reviews Advise the CCG on commissioning issues which need to be addressed / clinical policies which need to be reviewed or developed as a result of the individual case reviews Uphold Decision Appeal Appeals Panel Appeal Panel Membership:- Overturn Decision Case returned to IFR Panel GP(s)/Consultant(s) Consultant in Public Health Medicine Commissioners Lay Member(s) Public Health Specialist (not a member of the Panel) to prepare papers for the Appeal Panel and record the deliberations of the Panel 45 Accept Decision Appendix 2 - Ophthalmology Information Sheet West Sussex CCG Review Panel for Patients with Individual Needs GUIDANCE ON THE TREATMENT OF CHALAZIA The following guidance was written by a Consultant Ophthalmologist:- What is a chalazia? A chalazion is an enlargement of an oil-producing gland in the eyelid (the meibomian gland). It forms when the gland opening becomes clogged with oil secretions. It is not caused by an infection from bacteria, and it is not cancerous. A chalazion is sometimes confused with a stye, which also appears as a lump on the eyelid. A stye is a red, sore lump near the edge of the eyelid caused by an infected eyelash follicle. Initially, a chalazion may resemble a stye, but it usually grows larger, sometimes as large as a pea. Chalazia also tend to develop farther from the edge of the eyelid than styes. About 25% of chalazia have no symptoms and will disappear without any treatment. Sometimes, however, a chalazion may become red, swollen and tender. A larger usually upper lid chalazion may also cause blurred vision by distorting the shape of the eye. Occasionally, a chalazion can cause the entire eyelid to swell suddenly. How should chalazia be treated? Symptoms are treated with one or more of the following methods: Warm compresses help to clear the clogged gland. Soak a clean washcloth in hot water and apply the cloth to the lid for 10 - 15 minutes, three or four times a day until the chalazion is gone. You should repeatedly soak the cloth in hot water to maintain adequate heat. Antibiotic ointment may be prescribed if bacteria infect the chalazion. If a large chalazion does not respond to other treatments and affects vision, it may require incision and curettage. The procedure is usually performed under local anaesthesia in outpatients but children will require a general anaesthetic. A chalazion usually responds well to treatment, although some people are prone to recurrences. If a chalazion recurs in the same place, a biopsy to rule out sebaceous gland carcinoma may be indicated. 46 APPENDIX 3 Coastal West Sussex CCG Varicose Vein Referral Guidelines and Management Pathway Patient presents to GP with Varicose Veins Route 1 Route 3 Route 2 Trial of class I/II stockings¹ Venous Bleeding Or Above Knee Thrombophlebitis Failed Compression Exceptional circumstances YES Are any 2 of the following present? Treatment in Secondary care YES NO Secondary Care referral inappropriate 1. 1. Trial of class I/II compression stocking for 4 months 2. 3. 2. CEAP classification of venous disease 3. Ulcers without other skin changes may not be venous Check List for GP Referral: Confirmation that compression has been tried Document presence of ulceration or other skin changes Details of previous surgery/ injections History of possible/definite DVT History of previous limb or pelvic trauma History of previous long illness with bed rest History of abnormal clotting/anticoagulation Family history of clotting disorder Drug history especially oral contraception or HRT 1. Ulcer³ (active/healed) 2. Lipodermatosclerosis 3. Venous Eczema IFR CEAP grades ² 4b, 5 & 6 Are there any exceptional circumstances? - - YES Patients who meet the eligibility criteria are to be treated without applying to the IFR panel Referrals which do not meet the eligibility criteria are to be returned to GP Hospital trusts will not be paid for undertaking treatments that fall outside of the eligibility criteria Trusts will be audited to ensure that they treat patients who meet the eligibility criteria only. 47 48
