NHS Aylesbury Vale Clinical Commissioning Group and NHS Chiltern Clinical Commissioning Group Restricted Procedures,Treatments and Interventions 2016/17

© SCW CSU for NHS Aylesbury Vale Clinical Commissioning Group and NHS Chiltern Clinical Commissioning Group Restricted Procedures,Treatments and Interventions 2016/17 V7

Introduction The current procedures/treatments and interventions can be broadly classified into three categories:   

RED: Excluded – procedures not routinely funded by The Commissioner (formerly known as, including and not limited to, Low Priority, PLCV and Never Dos) AMBER: Procedures that require prior approval by written communication through the IFR team who manage these requests on behalf of the Commissioner (formerly known as threshold dependent procedures (TDP) GREEN: Funded Subject to Audit – procedures that are routinely funded subject to criteria and will be subject to audit of an agreed sample of activity.

Red - Procedures not routinely funded (excluded) These are procedures that will not be funded by The Commissioner due to a lack of clinical benefit, limited resource or the responsibility of specialised commissioning. Individual funding requests (IFR) may be made to the patient’s CCG for consideration, where exceptional circumstances exist via the IFR team through the IFR process, as outlined on the following website: http://www.fundingrequests.cscsu.nhs.uk/buckinghamshire/ Amber - Procedures that require prior approval For these procedures, it is known that the benefit from the intervention is expected to be more effective when the patient meets the criteria, as outlined on the following website. Prior approval is required for all procedures, treatments and interventions in this category. Where available a proforma/checklist is to be completed. http://www.fundingrequests.cscsu.nhs.uk/buckinghamshire/ Green - Funded and Subject to Audit For these procedures prior to referral and/or treatment, the patient must meet the criteria as outlined on the following website http://www.fundingrequests.cscsu.nhs.uk/buckinghamshire/ These cases will be audited and monitored for compliance against the criteria. Where patients do not meet the criteria, individual funding requests (IFR) must be made to the IFR service for consideration, where exceptional circumstances exist. For all categories - procedures carried out that do not follow the above outlined processes will not be paid for. Retrospective funding requests are not accepted and will not be funded. A list of procedures, treatments and interventions can be found in table 1. Please note: The table below states where the initial funding request needs to come from, this does not preclude other clinicians applying for funding especially if funding has not been applied for prior to referral into secondary care. In this instance, the provider should refer back to primary care. If a consultant has seen the patient in out-patients then the Consultant must obtain approval prior to surgery

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Table 1 – Please see below but also specific policies relating on http://www.fundingrequests.cscsu.nhs.uk/buckinghamshire/ Procedure / Treatment

Excluded

Prior Approval

Funded Subject to Audit

Funding requests required from

All specialties Biological Mesh Botulinum toxin Type A (Botox) for Hyperhidrosis Botulinum toxin Type A – Chronic Anal fissure Botulinum toxin Type A for chronic headaches (excluding migraines) Botulinum toxin Type A – Long term Bell’s Palsey Botulinum toxin Type A – Sialorrhoea (Severe Drooling) Botulinum toxin Type A – Spasticity Electrical stimulation (including Functional Electrical Stimulation) for Upper and Lower Limb Dysfunction Endoscopic Thoracic Sympathectomy for Facial Blushing and/or sweating Erectile Dysfunction treatments – Including: Erectile pumps/devices and psychosexual interventions Erectile Dysfunction treatments – Including: drugs sildenafil, vardenafil and tadalafil Excess Treatment Costs (ETCs) for non-commercial clinical trials Functional Electrical Stimulation in Drop Foot of Central Origin Gallstones (treatment of patients with previously symptomatic gallstones who are now free of symptoms) Hernia Surgery (Inguinal Hernia Surgery (Umbilical) Laparoscopic fundoplication for chronic reflux oesophagitis (funding for use in any other circumstance is excluded (Low Priority) Non pharmacological services for dementia patients Rectal Investigation and surgery Snoring and Sleep Apnoea Speech and Language Therapy in Parkinson’s Disease Surgical techniques for the treatment of Oesophageal Stricture

●

Consultant Consultant Consultant Consultant

● ● ●

Consultant Consultant Consultant Consultant

● ● ● ●

Consultant

●

GP

● ● ● ● ● ● ●

GP if outside of criteria N/A Consultant GP – if criteria not met GP GP Consultant

●

● ● ● ● ● Complementary medicine / alternative therapies ● Acupuncture Acupuncture of the treatment of chronic, non-specific low back ● pain Body Massage Functional Therapy Session Homeopathy –Complementary therapy Hypnosis Movement Therapy Osteopathy and Chiropractic Relaxation Therapy Session

● ● ● ● ● ● ● Cosmetic Procedures

Abdominoplasty, apronectomy (Tummy tucks) Aesthetic/cosmetic genital surgery – male or female Appliances & devices for cosmetic purposes (high-grade silicon cosmesis and/or prosthesis) Blepharoplasty – (upper and lower eye lid surgery) Body contouring procedures (buttock, thigh, arm lifts) Botox for cosmetic reasons , hyperhidrosis

GP GP Consultant GP GP GP GP GP GP GP GP GP

● ● ●

GP GP GP

● ● ●

GP GP GP

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Procedure / Treatment

Excluded

Prior Approval

Funded Subject to Audit

Funding application required from

Cosmetic Procedures (continued) Brachioplasty (arm lift) Breast asymmetry Breast augmentation Breast mastopexy Breast prosthesis removal or replacement Breast reduction Clitoroplasty Correction of hair loss (Alopecia) Correction of male pattern baldness Correction of Ptosis Corrective surgery to nipple Eflornithine for facial hirsutism Excision of skin tag of anus (not including fistula’s) Excision of sweat bearing glands Facelift (Rhytidectomy/ Surgical removal of wrinkles)/ Brow lift and Submental lipectomy Hair Transplantation / hair grafting Hymenopathy Labiaplasty Laser Treatment Laser removal of skin lesions (haemangioma, portwine stain, HHT) and excessive hirsutism Liposuction Male breast reduction (Gynaecomastia) Mammoplasty Pectus anomaly surgery Minor skin procedures (excluding skin cancers) Pinnaplasty (bat ears – adults and children) Reconstruction/Revision of breast excluding post breast cancer) Reconstruction/Revision of nose Reconstruction/Revision of external ear Reconstruction/Revision of body (excess skin removal for all areas) Reconstruction/Revision of body (excess skin removal for all areas) post bariatric surgery/weight loss Removal of lipomata Removal of supernumerary nipples Removal of Tattoos Revision of Breast Surgery Rhinoplasty (cosmetic nose surgery) Scar Revision (keloid and hypertrophic scars) Sebaceous cysts (pilar and epidermoid cysts) Seborrhoeic keratoses (benign skin growths, verrucas, warts), acne vulgaris, rosacea Skin resurfacing (dermabrasion, laser and chemical peels) Spider naevia Split earlobes, meatoplasty/ plastic operations on external ear (e.g. lobe repair) Telangiectasia

● ● ● ● ● ● ● ● ●

● ● ● ● ● ●

GP GP GP GP GP GP GP GP GP GP/Consultant GP GP GP GP GP

● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

© SCWCSU - NHS Aylesbury Vale Clinical Commissioning Group and NHS Chiltern Clinical Commissioning Group - Restricted Procedures,Treatments and Interventions 2016/17 V7

GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP GP

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Procedure / Treatment

Excluded

Prior Approval

Funded Subject to Audit

Funding application required from

Cosmetic Procedures (continued) GP GP

● ●

Vaginoplasty Xanthelasmas

Ear Nose and Throat ●

Adenoidectomy Grommets /Myringotomy Surgery in the management of chronic rhino sinusitis and nasal polyposis Tonsillectomy

● ●

●

ENT Consultant ENT Consultant ENT Consultant if outside of criteria GP

Gynaecology Intermediate Gynae Service Intermediate Gynae Service Consultant Intermediate Gynae Service

●

Dilation and curettage for abnormal uterine bleeding

●

Female Sterilisation and reversal Hysterectomy (excludes Cancer)

● ●

Uterine Artery Embolisation of Fibroids

Infertility treatments NHS Fertility Service NHS Fertility Service/GP if outside of criteria

●

Cryopreservation (male and female) In vitro fertilisation (including the prescriptions of infertility drugs) and ICSI (intracytoplasmic sperm injection) for infertile couples – Assisted Conception (excluding couples who fully meet the criteria)

●

Maxillofacial Manipulation of the Temporomandibular Joint together with intra-articular injection of steroids under general anaesthesia

NHS Maxillofacial Service

●

NHS Maxillofacial Service

●

Temporomandibular Joint Replacement

Mental Health GP if outside referral pathway into Mental Health GP if outside normal CFS/ME service GP if outside normal service

●

ADHD Treatment Pathway for Adults with Attention Deficit Hyperactivity Disorder ●

Chronic Fatigue Syndrome / Myalgic Encephalomyelitis inpatient stay

●

Referrals to Psychological Medicines Unit, Northwick Park

Ophthalmology ● Cataract removal in adults Chalazia (meibomian cysts)

● ●

Second eye cataract surgery Short sight/long sight corrective (laser) surgery (Refractive keratoplasty)

●

Optometrists/GP if outside of criteria GP Optometrists/GP if outside of criteria Optometrists/GP

Trauma and Orthopaedics Arthroscopic Lavage & Debridement for Patients with Osteoarthritis of the knee

●

Intermediate MSK Service

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Procedure / Treatment

Excluded

Prior Approval

Funded Subject to Audit

Funding application required from

Trauma and Orthopaedics continued Carpal Tunnel Syndrome Cortocosteroid injections for elbow tendinopathy (tennis elbow) Cortocosteroid injections for patellar tendinopathy (jumper’s knee)

Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service

●

● ● ●

Dupuytren’s Contracture (Palmar Fasciectomy) Facet Joint Injections (FJI) – Diagnostic

●

Facet Joint Injections (FJI) - Therapeutic Femoro-acetabular (Hip) Impingement (Arthroscopic and open Approaches) – Surgical Treatment - Hip Impingement surgery

● ● ●

Ganglion Surgery

●

Hip and Knee Replacement Surgery - follow up appointments

●

Hip Replacement Surgery

●

Hip Resurfacing for Advanced Arthropathy

● Knee Replacement Surgery Low-intensity pulsed ultrasound (LIPUS, marketed in the UK as Exogen© system) for delayed non-union fracture

● ●

Referral for Hip Joint Replacement (Revision) Surgery Referral for Knee Joint Replacement (Revision) Surgery Spinal manipulation for the treatment of chronic, non-specific low back pain Spinal Surgery (spinal fusion or discectomy) for the treatment of chronic non-specific low back Transforaminal epidural injections for sciatica (therapeutic and diagnostic use)

● ●

Intermediate MSK Service Intermediate MSK Service

● ●

Intermediate MSK Service Intermediate MSK Service Intermediate MSK Service

●

Treatment of bunions (hallux valgus) Trigger finger surgery

●

Ultrasound guided injections for hip pain (trochanteric bursitis and osteoarthritis of the hip)

●

Consultant

Respiratory Short Burst Oxygen Therapy(SBOT) for the relief of episodic breathlessness

●

Specialist Respiratory Service

Urology Botulinum Toxin Type A – Overactive Bladder Male Circumcision and revision surgery Penile prosthesis / enlargement Penile Rehabilitation following prostate surgery Vasectomy and reversal

● ●

Consultant

●

GP GP GP GP

●

GP

● ●

Vascular Surgery Varicose Veins

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Process for managing restricted procedures, treatments and interventions This document includes the absolute criteria which must be met in order for the patient to be treated and the associated charges to be paid by The Commissioner. It is important to note that the clinical case for an individual’s treatment should be assessed on its own merits and if a patient does not meet the criteria for funding an application can be made via an Individual Funding Request. The NHS Confederation document "Priority setting: managing individual funding requests", drafted for Primary Care Trusts in 2008, gives a clear definition of an individual funding request as follows:"An Individual Funding Request (IFR) is a request to a CCG (formerly PCT) to fund healthcare for an individual who falls outside the range of services and treatments that the CCG (formerly PCT) has agreed to commission. There are several reasons why a CCG may not be commissioning the healthcare intervention for which funding is sought.    

It might not have been aware of the need for this service and so has not incorporated it into the service specification It may have decided to fund the intervention for a limited group of patients that excludes the individual for whom the request is made It may have decided not to fund the treatment because it does not provide sufficient clinical benefit and/or does not provide value for money It may have accepted the value of the intervention but decided it cannot be afforded in the current year

Such requests should not be confused with  Decisions that are related to care packages for patients with complex healthcare needs which include Continuing Health Care packages of care. “ The above list is not exhaustive and is at the sole discretion of the Commissioners. Where patients do not meet criteria in the Amber category, or are under the Red category, Individual Funding Requests will usually be considered on the basis of ‘exceptionality’. A guide to what constitutes ‘exceptionality’ or ‘exceptional health need’, can be found here: http://www.fundingrequests.cscsu.nhs.uk/wp-content/uploads/2013/10/Exceptional-Health-Need-guide-forpatients-and-clinicians-April-2013.pdf

Central to the CCG’s consideration of IFRs, is the question: “Why should this treatment be provided for this patient, when it would not be funded for other patients who have the same, or a substantively similar, condition?” If funding is to be agreed for the proposed treatment, there must be some unusual, unpredictable or unique factor about the patient’s clinical circumstances, which suggests that:  the presentation/effect of the condition in the patient differs significantly from that found in the general population of patients with the condition and as a result, 

the patient is likely to gain significantly more benefit from that treatment than might generally be expected for these patients.

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In addition to this: There should be sufficient evidence of the effectiveness of the treatment in bringing about the expected benefit for the patient. IFR must be supported by a summary statement of clinical evidence for the proposed treatment. NB: It is the requesting clinician’s responsibility, where relevant, to set out the case for an exception to be made. Please note: It is not possible to predict in advance what might provide a basis for exceptional funding, given the individual nature of each patient’s clinical circumstances. Meeting the accepted indications for a treatment does not, in itself, provide a basis for an exception. The fact that a patient is likely to respond to the requested treatment does not, in itself, provide a basis for an exception. Non-medical or social factors will rarely be considered as a basis for an exception. Social value judgements will not be considered as a basis for an exception. For a further explanation of exceptionality, please refer to the UK Faculty of Public Health document available at http://www.fph.org.uk/policy_reports (accessed 15/01/15) and http://www.fundingrequests.cscsu.nhs.uk/wp-content/uploads/2013/10/Exceptional-Health-Need-guide-forpatients-and-clinicians-April-2013.pdf

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Figure 1 – Process for Managing Policies. NHS Aylesbury Vale Clinical Commissioning Group and NHS Chitern Clinical Commissioning Group process for restricted treatments, procedures and interventions Referral arrives into Provider for a restricted treatment / procedure / intervention/ drug

RED or Amber or GREEN procedure the following process must be followed

RED or Amber procedure with no IFR Prior approval GREEN procedure outside of criteria OR Retrospective funding request (these will not be paid)

Approval must be obtained prior to First OPA

RED

NO

AMBER

Refer Individual Funding Request to bucks.ifrrequests@ nhs.net for consideration

GREEN

Does not meet criteria Seek prior approval from bucks.ifrrequests@ nhs.net

Declined

REJECTED - back to referrer explaining why

NO

Check against policy criteria

Criteria met

Approved by IFR Not treated within relevant timescale

Document that patient meets criteria (proforma / case notes)

Treat Patient

Approved by IFR Treat Patient within timescale 6 months for procedures 12 months for drugs

Treat Patient within timescale 6 months for procedures 12 months for drugs

Prior approval considered by IFR

Treat Patient

Rejected AVCCG and CCCG audit and review

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Description of Prior Approval Process – All Providers: N.B. For clinically urgent requests which require prior approval there is a ‘fast-track’ process which manages these requests within 48 hours of receiving a complete case. Therefore these will not delay clinically urgent treatments where the patient meets the criteria. This process applies for referrals into All Providers for restricted procedures, treatments and interventions as outlined in Table 1. The process is: 1. Check the procedure is on the list (Table 1). 2. Check the policy for this procedure and assess the patient against the policy as per the categories below: RED Red procedures without Individual Funding Requests must not be treated as they are not routinely commissioned. Reject Referral and send back to referrer explaining why.

AMBER Check prior approval has been granted. If yes, proceed. If none, apply for IFR

GREEN Check criteria. If patient is outside of criteria. Reject referral and send back to referrer explaining why or you have the option to apply for IFR

3. If prior approval is in place for Red / Amber categories or if patient meets criteria for Green, patients can be invited for a First Outpatient Attendance for assessment. PLEASE NOTE: Where consideration is required for assessment of the patient’s health needs (and can only be determined by the Consultant in an outpatient assessment) then the patient should be invited for an assessment for an opinion only. 4. Decision made to clinically proceed based on initial assessment: No – Reject back to referrer explaining why Yes – Proceed 5. What process is followed for the required procedure / treatment, check is it Red, Amber or Green: RED Clinician believes patient has extenuating circumstances, exceptional health need and completes an Individual Funding Requests [email protected] for necessary approval and funding. If IFR rejected, patient referred back to referrer. Where IFR approved, proceed to treat.

AMBER Prior approval required from AVCCG and CCCGs. Clinician completes form detailing need for treatment and required procedure/ dosage or regimen to [email protected]. Where prior approval granted, proceed to treat. Where prior approval rejected, refer back to referrer explaining why

GREEN Check criteria. If patient is outside of criteria, reject referral and send back to referrer explaining why. If referrer believes patient has extenuating circumstance and exceptional health need, clinicians to apply for IFR. If patient meets the criteria, proceed with treatment documenting how patient meets criteria (proforma / patient notes). AVCCG and CCCG to audit and review compliance

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6. Red Policies – These procedures are not commissioned by The Commissioner. The clinician can apply for IFR if they believe the patient has extenuating circumstances and will benefit from procedure / treatment /intervention. 7. Amber Policies – Written communication must be submitted to the IFR Team on behalf of the CCGs via [email protected] for prior approval, completing the appropriate proforma and explaining the patient’s need for treatment. The team will respond within 3-5 working days of the decision being made. Approved – Where patients are approved, proceed with treatment. Providers must treat patients within 6 months of approval date for procedures/interventions or 12 months of approval for drug treatment. Not Approved – Where patients are not approved DO NOT proceed with treatment and refer back to original referrer explaining why with necessary management plan. 8. Green Policies – Does the patient meet the criteria within the policy? No – DO NOT treat. If the patient does not meet the criteria in the policy, The Commissioner will not fund the procedure. The clinician can apply for IFR if believes patient has extenuating circumstances and will benefit from procedure / treatment/ intervention. Otherwise refer back to the original referrer Yes – Proceed with treatment. Document in proforma / patients notes where criteria have been met according to the individual policy.

PLEASE NOTE: Retrospective funding will not be considered or agreed to.

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