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Treatment policies

Background
Which treatments are covered by policies?
What does each policy detail?
What types of treatments do the policies cover?
Principles underpinning each Treatment Policy
Individual Funding Requests (IFR) and Exceptionality
Clinician's right to seek specialist advice
How does the IFR Application System work in practice?
Monitoring and Review of Commissioning Policies
Lifestyle Factors and Surgery
Psychological Factors and Surgery

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 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.

Birmingham CrossCity, Birmingham South Central and Solihull CCGs undertook period of public engagement in early 2016 to ensure that patients and other stakeholders had the opportunity to give their views on the proposed new harmonised policies. 

The final engagement report can be read here

View the Harmonised Treatment Policies Equality Assessment Report here

View the Glossary of Terms for Treatment Policies here

View the Harmonised Treatment Policies Document here

View the Harmonised Treatment Policies Acute Provider Implementation notice letter here

View the Harmonised Treatment Policies Finance/Activity trend analysis - 17/18 latest here

View the Treatment Policies Reference Library here

Which treatments are covered by policies?

Policy Document Treatment Policy Category Treatment Policy Detail Easy Read Leaflet Patient Treatment Decision Aid
Adenoidectomy Restricted  Adenoidectomy Currently in development   
Cosmetic Surgery Abdominoplasty / Apronectomy              Not routinely commissioned Abdominoplasty / Apronectomy Currently in development   
Cosmetic Surgery Thigh lift, Buttock Lift and Arm Lift, Excision of Redundant Skin or Fat            Not routinely commissioned Thigh lift, Buttock Lift and Arm Lift, Excision of Redundant Skin or Fat   Currently in development   
Cosmetic Surgery Liposuction Not routinely commissioned Liposuction Currently in development  
Cosmetic Surgery Breast Augmentation
a) Non breast cancer
b) Breast cancer


Not routinely commissioned
Restricted
Breast Augmentation Currently in development   
Cosmetic Surgery Breast Reduction
a) Non breast cancer
b) Breast cancer      

Not routinely commissioned
Restricted 
Breast Reduction Currently in development   
Cosmetic Surgery Mastopexy (Breast Lift)
a) Non breast cancer
b) Breast cancer


Not routinely commissioned
Restricted 
Mastopexy (Breast Lift) Currently in development   
Cosmetic Surgery Inverted Nipple Correction
a) Non breast cancer
b) Breast cancer


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

Rheumatoid arthritis
Hysterectomy for Heavy Menstrual Bleeding    Restricted  Hysterectomy for Heavy Menstrual Bleeding Currently in development  Heavy menstrual bleeding menorrhagia
Diagnostic Hysteroscopy for Menorrhagia    Not routinely commissioned  Diagnostic Hysteroscopy for Menorrhagia Currently in development  Heavy menstrual bleeding menorrhagia
Groin Hernia Repair    Restricted  Groin Hernia Repair Currently in development  Inguinal hernia
Knee Replacement Surgery   Restricted  Knee Replacement Surgery Currently in development  Osteoarthritis of the knee

Rheumatoid arthritis
Penile Implants    Not routinely commissioned  Penile Implants Currently in development   
Tonsillectomy    Restricted  Tonsillectomy Currently in development   
Trigger Finger   Restricted  Trigger Finger Currently in development   
Varicose Veins    Restricted  Varicose Veins Varicose Veins Leaflet
 

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 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.

This position is supported by the Birmingham CrossCity CCG ethical-framework-version-1-march-2013.

The Individual Funding Request Policy can be read here.

The Individual Funding Request Application Form can be read here.

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 1408

Email address for Individual Funding Request team at Birmingham CrossCity 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 body mass index of 35 or greater and 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. 

Psychological 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.

The following treatment policies are currently in development:

Other Existing Local CCG Policies

 

Treatment Policy Category Treatment Policy Detail Easy Read Leaflet Patient Treatment Decision Aid
Assisted Conception Restricted             Assisted conception  Currently in development  
Bariatric Surgery Restricted              Bariatric Surgery  Currently in development  
Carpal Tunnel Restricted              Carpal Tunnel Currently in development  Carpal Tunnel Syndrome
Complementary therapies and alternative medicines Not routinely commissioned Complementary therapies and alternative medicines  Currently in development   
Diagnostic Arthroscopy of the Knee Joint Not routinely commissioned Diagnostic Arthroscopy of the Knee Joint  Currently in development   
Facet joint and epidural injections Restricted              Facet joint and epidural injections  Currently in development   
Port Wine Stain Not routinely commissioned Currently in development   
Rosecea – Laser Treatment Not routinely commissioned Currently in development   
Planned caesarean section Restricted- RCOG Guidelines Currently in development  Birth options after previous C-Section
Laser treatment for myopia (keratoplasty) Not routinely commissioned Currently in development   
Dupuytren Contracture Restricted Dupuytren Contracture  Currently in development   
Reversal of male and female sterilisation (including vasectomies) Not routinely commissioned Currently in development   
Any treatment purporting to treat allergy as a cause of chronic (post-viral) fatigue syndrome Not routinely commissioned Currently in development   
Treatment of myalgic encephalomyelitis Not routinely commissioned Currently in development   
Any treatment of candida hypersensitivity syndrome Not routinely commissioned Currently in development   
Radiotherapy for age-related macular degeneration of the eye Not routinely commissioned Currently in development   
Nucleoplasty (percutaneous coblation disc herniation) Not routinely commissioned Currently in development   
Arthroscopic washout Not routinely commissioned Currently in development   
Use of dilators or microwaves for benign prostatic hyperplasia Not routinely commissioned Currently in development   
Use of lithiotripsy to treat small asymptomatic renal calculi Not routinely commissioned Currently in development   
Congenital vascular abnormalities Restricted Currently in development   
Photodynamic therapy Restricted Currently in development   
Surgical removal of mucoid cysts at DIP joint Restricted Currently in development   
NIV & CPAP Machine Restricted Currently in development   
Hyperbaric Oxygen Therapy Restricted Currently in development   
Removal of ear wax Restricted (established primary  care pathway in Solihull) Currently in development   
Allergy Testing Restricted Currently in development  
Acupuncture Restricted Currently in development  
Carotid artery surgery for asymptomatic patients with carotid artery disease Restricted Currently in development  
Botulinum toxin for facial ageing Not routinely commissioned Currently in development  
Non-emergency patient transport Restricted

NEPT - Patient Charter and Eligibility Criteria

NEPT on a page

Currently in development  
Dilation of Cervix   Dilation of Cervix Uteri Curettage of Uterus  Currently in development  

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