Treatment policies

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Background

Since 2013 the following Clinical Commissioning Groups (CCG) and their respective Local Authority Public Health Commissioners have worked collaboratively to develop this harmonised core set of 21 treatment policies:

  • NHS Birmingham CrossCity CCG
  • NHS Birmingham South Central CCG
  • NHS Sandwell and West Birmingham CCG
  • NHS Solihull CCG
  • NHS Walsall CCG
  • NHS Wolverhampton CCG
The aim is to:

  • ensure policies incorporate the most up-to-date published clinical evidence so that we prioritise funded treatments that are proven to have clinical benefit for patients.
  • stop variation in access to NHS funded services across Birmingham, Solihull and the Black Country (sometimes called the ‘postcode lottery’ in the media) and allow fair and equitable treatment for all local patients.
  • ensure access to NHS funded treatment is equal and fair, whilst considering the needs of the overall population and evidence of clinical and cost effectiveness.

SWB CCG ran a listening exercise from 16 January 2017 - 13 February 2017 to gather public and patient views on the principles that were used to review the policies on  Procedures of Lower Clinical Value (PLCV), namely;

  • To offer procedures and treatments consistently and fairly to patients
  • To end the ‘postcode lottery’ by having the same eligibility criteria for treatments regardless of where patients live
  • To ensure that policies meet the latest national clinical guidance and are supported by robust clinical evidence
  • To stop using treatments that do not have any benefits, or have a very limited evidence base
  • To prioritise treatments which provide the greatest benefits to patients
  • To stop offering cosmetic treatments except where deemed medically appropriate, i.e  if a child has bat ears and they are being bullied at school

The listening exercise report was presented to and signed off at our March Governing Body and the report can be viewed by clicking here.

Further materials 

Which treatments are covered by the policies? 

Policy Document Treatment Policy Category Treatment Policy Detail Patient Treatment Decision Aid 
Adenoidectomy   Restricted  document Adenoidectomy(76 KB)  
Cosmetic Surgery Abdominoplasty / Apronectomy              Not routinely commissioned document Abdominoplasty / Apronectomy (75 KB)  
Cosmetic Surgery Thigh lift, Buttock Lift and Arm Lift, Excision of Redundant Skin or Fat            Not routinely commissioned document Thigh lift, Buttock Lift and Arm Lift, Excision of Redundant Skin or Fat (75 KB)    
Cosmetic Surgery Liposuction Not routinely commissioned document Liposuction (74 KB)  
Cosmetic Surgery Breast Augmentation
a) Non breast cancer
b) Breast cancer


Not routinely commissioned
Restricted
document Breast Augmentation (76 KB)  
Cosmetic Surgery Breast Reduction
a) Non breast cancer
b) Breast cancer      

Not routinely commissioned
Restricted 
document Breast Reduction(78 KB)  
Cosmetic Surgery Mastopexy (Breast Lift)
a) Non breast cancer
b) Breast cancer


Not routinely commissioned
Restricted 
document Mastopexy (Breast Lift) (76 KB)  
Cosmetic Surgery Inverted Nipple Correction
a) Non breast cancer
b) Breast cancer


Not routinely commissioned 
Restricted
document Inverted Nipple Correction (75 KB)  
Cosmetic Surgery Gynaecomastia (Male Breast Reduction) Not routinely commissioned  document Gynaecomastia (Male Breast Reduction) (75 KB)  
Cosmetic Surgery Labiaplasty Restricted  document Labiaplasty (76 KB)  
Cosmetic Surgery Vaginoplasty Restricted  document Vaginoplasty (76 KB)  
Cosmetic Surgery Pinnaplasty Not routinely commissioned  document Pinnaplasty (75 KB)  
Cosmetic Surgery Repair of Ear Lobes Not routinely commissioned  document Repair of Ear Lobes (75 KB)  
Cosmetic Surgery Rhinoplasty Restricted  document Rhinoplasty (75 KB)  
Cosmetic Surgery Face Lift or Brow Lift (Rhytidectomy) Restricted  document Face Lift or Brow Lift (Rhytidectomy) (76 KB)  
Cosmetic Surgery Hair Depilation (Hirsutism) Restricted document Hair Depilation (Hirsutism)  (76 KB)  
Cosmetic Surgery Alopecia (Hair Loss) Not routinely commissioned document Alopecia (Hair Loss) (75 KB)  
Cosmetic Surgery Removal of Tattoos / Surgical correction of body piercings and correction of respective problems Not routinely commissioned  document Removal of Tattoos / Surgical correction of body piercings and correction of respective problems(75 KB)  
Cosmetic Surgery Removal of Lipomata Restricted document (75 KB) documentRemoval of Lipomata (75 KB)  
Cosmetic Surgery Removal of Benign or Congenital Skin Lesions Restricted  document Removal of Benign or Congenital Skin Lesions (76 KB)  
Cosmetic Surgery Medical and Surgical Treatment of Scars and Keloids Not routinely commissioned  document Medical and Surgical Treatment of Scars and Keloids(76 KB)  
Cosmetic Surgery Botulimium Toxin Injection for the Ageing Face Not routinely commissioned  document Botulimium Toxin Injection for the Ageing Face (75 KB)  
Cosmetic Surgery Treatment for Viral Warts Restricted  document Treatment for Viral Warts (75 KB)  
Cosmetic Surgery Thread / Telangiectasis / Recticular Veins Not routinely commissioned  document Thread / Telangiectasis / Recticular Veins (76 KB)  
Cosmetic Surgery Rhinophyma Not routinely commissioned  document Rhinophyma (75 KB) document   
Cosmetic Surgery Resurfacing Procedures: Dermbrasion, Chemical Peels and Laser Treatment Not routinely commissioned document Resurfacing Procedures: Dermbrasion, Chemical Peels and Laser Treatment (75 KB)  
Cosmetic Surgery Other Cosmetic Procedures Not routinely commissioned  document Other Cosmetic Procedures (77 KB)  
Cosmetic Surgery Revision of Previous Cosmetic Surgery Procedures Not routinely commissioned  document Revision of Previous Cosmetic Surgery Procedures(74 KB)  
Back Pain
  Restricted  document Back Pain (139 KB)
 
Botulinium Toxin for Hyperhydrosis   Not routinely commissioned  document Botulinium Toxin for Hyperhydrosis(74 KB) 
 
Cataracts   Restricted document Cataracts (229 KB) 
pdf Cataracts(65 KB)
Cholecystectomy for Asymptomatic Gallstones   Not routinely commissioned documentCholecystectomy for Asymptomatic Gallstones (76 KB) pdf Gallstones(69 KB)
Male Circumcision   Restricted document Male Circumcision (75 KB)  
Dilation and Curettage (D&C) for Menorrhagia   Not routinely commissioned document Dilation and Curettage (D&C) for Menorrhagia (74 KB) pdf Heavy menstrual bleeding menorrhagia(74 KB)
Eyelid Surgery (Upper and Lower) Blepharoplasty   Restricted document Eyelid Surgery (Upper and Lower) Blepharoplasty (76 KB)  
Ganglion    Restricted  document Ganglion (74 KB)  
Grommets    Restricted  document Grommets (75 KB) pdf Glue ear(69 KB)
Haemorrhoidectomy    Restricted  documentHaemorrhoidectomy(76 KB) 
 
Hip Replacement Surgery   Restricted  document Hip Replacement Surgery (79 KB) pdfOsteoarthritis of the hip (68 KB) 

pdfRheumatoid arthritis (76 KB)
Hysterectomy for Heavy Menstrual Bleeding    Restricted  document Hysterectomy for Heavy Menstrual Bleeding (78 KB) pdf Heavy menstrual bleeding menorrhagia(74 KB)
Diagnostic Hysteroscopy for Menorrhagia    Not routinely commissioned  document Diagnostic Hysteroscopy for Menorrhagia (73 KB) pdf Heavy menstrual bleeding menorrhagia(74 KB)
Groin Hernia Repair    Restricted  document Groin Hernia Repair (236 KB) pdf Inguinal hernia (66 KB)
Knee Replacement Surgery   Restricted  document Knee Replacement Surgery (76 KB) pdfOsteoarthritis of the knee(70 KB) 

pdfRheumatoid arthritis (76 KB)
Penile Implants    Not routinely commissioned  document Penile Implants(75 KB)  
Tonsillectomy    Restricted  documentTonsillectomy(75 KB)  
Trigger Finger   Restricted  document Trigger Finger(75 KB)  
Varicose Veins    Restricted  document Varicose Veins(76 KB)  

Other Existing Local CCG Policies

Treatment Policy Category Treatment Policy Detail
Routine Ear Irrigation  Not routinely commissioned Routine Ear Irrigation 
Carpal Tunnel Restricted              Carpal Tunnel
Arthroscopy of the Knee Joint Restricted Arthroscopy of the Knee Joint 
Joint Injections (non spiral) Restricted              Joint injections (non spiral)
Anal Skin Tags Restricted Anal Skin Tags
Reversal of Male Sterilisation  Not routinely commissioned Reversal of Male Sterilisation 
Reversal of Female Sterilisation  Not routinely commissioned Reversal of Female Sterilisation 
Laser Surgery for Short-Sightedness (Myopia) Not routinely commissioned Laser Surgery for Short-Sightedness (Myopia)
Botlinum Toxin Type A for Spasticity Restricted Botlinum Toxin Type A for Spasticity
Complementary Medicines Therapies Not routinely commissioned Complementary Medicines Therapies
Extracorporeal Shockwave Therapy for Refractory Plantar Fasciitis Not routinely commissioned Extracorporeal Shockwave Therapy for Refractory Plantar Fasciitis
Extracorporeal Shockwave Therapy for Refractory Achilles Tendinopathy Not routinely commissioned Exracorporeal Shockwave Therapy for Refractory Achilles Tendinopathy
Inpatient Cognitive Behavioural Therapy Residential Placements for CFS ME Not routinely commissioned Inpatient Cognitive Behavioural Therapy Residential Placements for CFS ME
Dupuytrens-Contracture Restricted Dupuytrens-Contracture
Skin Hypo Pighmentation  Not routinely commissioned Skin Hypo Pighmentation 

Very Low Calorie Diets Not routinely commissioned  Very low calorie diets
Please click here for all the Local Policies. 

What does each policy detail?

Each treatment policy states whether the treatment or procedure is:

  • Not routinely commissioned: would require an Individual Funding request to demonstrate clinical exceptionality or
  • Restricted: funded if particular clinical criteriand thresholds apply
There are also:

  • Short summary explanation of what the procedure entails
  • For ‘Restricted’ procedures what the clinical thresholds for treatment are.
  • Summary of what clinical guidance commissioners have used to inform the detail of the commissioning policy, e.g. NICE, Royal Colleges or Other Clinical Associations
  • Each policy is then subject to an Equality Impact Assessment review.

What types of treatments do the policies cover?

The policies cover a range clinical treatments which are:

  • procedures that are identified as being relatively ineffective (e.g. grommets and myringotomy, and certain spinal procedures for back pain) or;
  • identified cosmetic procedures or;
  • effective procedures in mild cases where the balance between benefit and risk is close (e.g. cataract surgery and primary hip or knee replacement) or;
  • effective, but where other cost-effective alternatives should be tried first (e.g. hysterectomy for heavy menstrual bleeding)

Principles underpinning each Treatment Policy

Commissioning decisions by CCG Commissioners are made in accordance with the commissioning principles set out below, and in the Birmingham, Solihull and Black Country CCGs’ Individual Funding Request Policy:

  • CCG Commissioners require clear evidence of clinical effectiveness before NHS resources are invested in the treatment.
  • CCG Commissioners require clear evidence of cost effectiveness before NHS resources are invested in the treatment
  • The cost of the treatment for this patient and others within any anticipated cohort is relevant factor.
  • CCG Commissioners will consider the extent to which the individual or patient group will gain benefit from the treatment
  • CCG Commissioners will balance the needs of each individual against the benefit which could be gained by alternative investment possibilities to meet the needs of the community
  • CCG Commissioners will consider all relevant national standards and take into account all proper and authoritative guidance
  • Where treatment is approved CCG Commissioners will respect patient choice as to where treatment is delivered.

Individual Funding Requests (IFR) and Exceptionality

We recognise there may be exceptional circumstances where it is clinically appropriate to fund each of the procedures listed in this policy and these will be considered on case-by-case basis. Funding for cases where either; a) the clinical threshold criteriis not met, or b) the procedure is not routinely funded, will be considered by the CCGs following application to the CCG’s Individual Funding Request Panel, whereby the IFR process will be applied.

For more information on IFR's please click here: http://sandwellandwestbhamccg.nhs.uk/freedom-of-information/our-policies-and-procedures/individual-funding-requests-ifr

Clinician's right to seek specialist advice? 

In cases of diagnostic uncertainty, the scope of this policy does not exclude the Clinician’s right to seek specialist advice.  This advice can be accessed through a variety of different mediums and can include both face to face specialist contact, as well as different models of consultant and specialist nurse advice and guidance virtually. 

How does the IFR Application System work in practice? 

Commissioners, GPs, service providers and clinical staff treating registered patients of the CCGs are expected to implement this policy.  When procedures are undertaken on the basis of meeting the criteria specified within the policy, this should be clearly documented within the clinical notes.  Failure to do so will be considered by the CCGs as lack of compliance.

Patients with problems or conditions that might require treatments included in this policy should be referred to a consultant or specialist only;

  • After a clinical assessment is made by the GP or Consultant; AND
  • The patient meets all the criteria set out in the policy.
GPs wishing to seek a specialist opinion for patients who meet the above criteria, should ensure the essential clinical information is included in the referral letter confirming the patient has been assessed in line with this policy.

GPs, Consultants in Secondary Care and provider finance departments need to be aware that the CCG will not pay for the procedures listed in this policy unless the patient meets the criteria outlined in this policy.

The CCGs recognise there will be exceptional, individual or clinical circumstances when funding for treatments designated as low priority will be appropriate.

Where a treatment is either not routinely funded, or the patient does not meet the specified clinical criteria, this means the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG. 

Individual Funding Requests should only be sent to the respective ‘nhs.net’ accounts detailed below. Guidance regarding IFRs and an application form, can be found here. 

IFR contact information

Individual Funding Request Case Manager
Floor Two, Kingston House
438 High Street
West Bromwich
West Midlands
B70 9LD

Telephone: 0121 612 1660

Email address for Individual Funding Request team at Sandwell and West Birmingham CCG:This email address is being protected from spambots. You need JavaScript enabled to view it.                           

Lifestyle factors and surgery 

Lifestyle factors can have an impact on the functional results of some elective surgery.  In particular, smoking is well known to affect the outcomes of some foot and ankle procedures.  In addition, many studies have shown that the rates of postoperative complications and length of stay are higher in patients who are overweight or who smoke.

Therefore, to ensure optimal outcomes, all patients who smoke or have a high body mass index are being considered for referral to Secondary Care, should be able to access CCG and Local Authority Public Health commissioned smoking cessation and weight reduction management services prior to surgery.

Patient engagement with these ‘preventive services’ may influence the immediate outcome of surgery.  While failure to quit smoking, or lose weight will not be a contraindication for surgery, GPs and Surgeons should ensure patients are fully informed of the risks associated with the procedure in the context of their lifestyle. 

Pschological factors and surgery

Commissioners acknowledge that there is a psychological dimension for patients in seeking or considering the option of treatment and surgery. However because there are no universally accepted and objective measures of psychological distress and therefore such factors are not taken in account in any policy clinical thresholds. Nevertheless there always remains the option of an application to demonstrate clinical exceptionality through IFR process as detailed above.