Treatment Policies

Background

Since 2013 the following clinical commissioning groups (CCGs) 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 (now Birmingham and Solihull CCG)
  • NHS Birmingham South Central CCG (now Birmingham and Solihull CCG)
  • NHS Solihull CCG (now Birmingham and Solihull CCG)
  • NHS Sandwell and West Birmingham 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.

Birmingham and Solihull CCG 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. You can find out more below:

Restricted procedures

Not normally funded procedures

Which treatments are covered by policies?

Policy document Treatment policy Category Treatment policy detail Patient treatment leaflet
Adenoidectomy   Restricted  Adenoidectomy Adenoidectomy 
Cosmetic surgery Abdominoplasty / Apronectomy              Not routinely commissioned Abdominoplasty / Apronectomy  Abdominoplasty / Apronectomy 
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    Thigh lift, buttock lift and arm lift, excision of redundant skin or fat 
Cosmetic surgery Liposuction Not routinely commissioned Liposuction  Liposuction 
Cosmetic surgery Breast augmentation
a) Non breast cancer
b) Breast cancer
Not routinely commissioned
Restricted
Breast augmentation  Breast augmentation 
Cosmetic surgery Breast reduction
a) Non breast cancer
b) Breast cancer      
Not routinely commissioned
Restricted 
Breast reduction  Breast reduction 
Cosmetic surgery Mastopexy (Breast Lift)
a) Non breast cancer
b) Breast cancer
Not routinely commissioned
Restricted 
Mastopexy (breast lift)  Mastopexy (breast lift) 
Cosmetic surgery Inverted nipple correction
a) Non breast cancer
b) Breast cancer
Not routinely commissioned 
Restricted
Inverted nipple correction  Inverted nipple correction 
Cosmetic surgery Gynaecomastia (male breast reduction) Not routinely commissioned  Gynaecomastia (male breast reduction)  Gynaecomastia (male breast reduction)  
Cosmetic surgery Labiaplasty Restricted  Labiaplasty  Labiaplasty 
Cosmetic surgery Vaginoplasty Restricted  Vaginoplasty  Vaginoplasty 
Cosmetic surgery Pinnaplasty Not routinely commissioned  Pinnaplasty  Pinnaplasty 
Cosmetic surgery Repair of ear lobes Not routinely commissioned  Repair of ear lobes  Repair of ear lobes 
Cosmetic surgery Rhinoplasty Restricted  Rhinoplasty  Rhinoplasty 
Cosmetic surgery Face lift or brow lift (Rhytidectomy) Restricted  Face lift or brow lift (Rhytidectomy)  Face lift or brow lift (Rhytidectomy) 
Cosmetic surgery Hair depilation (Hirsutism) Restricted Hair depilation (Hirsutism) 
Hair depilation (Hirsutism) 
Cosmetic surgery Alopecia (hair loss) Not routinely commissioned Alopecia (hair loss)  Alopecia (hair loss) 
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  Removal of tattoos / surgical correction of body piercings and correction of respective problems  
Cosmetic surgery Removal of lipomata Restricted Removal of lipomata  Removal of lipomata 
Cosmetic surgery Removal of benign or congenital skin lesions Restricted  Removal of benign or congenital sSkin lesions  Removal of benign or congenital skin lesions 
Cosmetic surgery Medical and surgical treatment of scars and keloids Not routinely commissioned  Medical and surgical treatment of scars and keloids  Medical and surgical treatment of scars and keloids 
Cosmetic surgery Botulimium toxin injection for the ageing face Not routinely commissioned  Botulimium toxin injection for the ageing face  Botulimium toxin injection for the ageing face 
Cosmetic surgery Treatment for viral warts Restricted  Treatment for viral warts  Treatment for viral warts 
Cosmetic surgery Thread / telangiectasis / recticular veins Not routinely commissioned  Thread / telangiectasis / recticular veins  Thread / telangiectasis / recticular veins 
Cosmetic surgery Rhinophyma Not routinely commissioned  Rhinophyma 
Rhinophyma 
Cosmetic surgery Resurfacing procedures: Dermbrasion, chemical peels and laser treatment Not routinely commissioned Resurfacing procedures: Dermbrasion, chemical peels and laser treatment  Resurfacing procedures: Dermbrasion, chemical peels and laser treatment 
Cosmetic surgery Other cosmetic procedures Not routinely commissioned  Other cosmetic procedures  Other cosmetic procedures 
Cosmetic surgery Revision of previous cosmetic surgery procedures Not routinely commissioned  Revision of previous cosmetic surgery procedures  Revision of previous cosmetic surgery procedures 
Back pain   Restricted  Back pain  Back pain 
Botulinium toxin for hyperhydrosis   Not routinely commissioned  Botulinium toxin for hyperhydrosis  Botulinium toxin for hyperhydrosis 
Cataracts Restricted Cataracts  Cataracts 
Cholecystectomy for asymptomatic gallstones Not routinely commissioned Cholecystectomy for asymptomatic gallstones  Cholecystectomy for asymptomatic gallstones 
Male circumcision Restricted Male circumcision  Male circumcision 
Dilation and curettage (D&C) for Menorrhagia Not routinely commissioned Dilation and curettage (D&C) for menorrhagia  Dilation and curettage (D&C) for menorrhagia 
Eyelid surgery (upper and lower) blepharoplasty Restricted Eyelid surgery (upper and lower) blepharoplasty  Eyelid surgery (upper and lower) blepharoplasty 
Ganglion  Restricted  Ganglion  Ganglion 
Grommets  Restricted  Grommets  Grommets 
Haemorrhoidectomy  Restricted  Haemorrhoidectomy  Haemorrhoidectomy 
Hip Replacement Surgery Restricted  Hip replacement surgery  Hip replacement surgery 
Hysterectomy for heavy menstrual bleeding  Restricted Hysterectomy for heavy menstrual bleeding  Hysterectomy for heavy menstrual bleeding 
Diagnostic hysteroscopy for menorrhagia  Not routinely commissioned  Diagnostic hysteroscopy for menorrhagia  Diagnostic hysteroscopy for menorrhagia 
Groin hernia repair  Restricted  Groin hernia repair  Groin hernia repair 
Knee replacement surgery Restricted  Knee replacement surgery  Knee replacement surgery 
Penile implants  Not routinely commissioned  Penile implants  Penile Implants
Tonsillectomy  Restricted  Tonsillectomy  Tonsillectomy 
Trigger finger Restricted  Trigger finger  Trigger finger 
Varicose veins  Restricted  Varicose veins  Varicose veins 

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 criteria and 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 of clinical treatments which are:

  • Procedures that are identified as being relatively ineffective (e.g. grommets and myringotomy, and certain spinal procedures for back pain) ;
  • Identified cosmetic procedures ;
  • Effective procedures in mild cases where the balance between benefit and risk is close (e.g. cataract surgery and primary hip or knee replacement) ;
  • 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 criteria is 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 and Solihull CCG Ethical framework for priority setting and resource allocation.

You can also read the following:

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?

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 in the Collaborative commissioning policy: Individual Funding Requests and there is also a separate Individual Funding Requests (IFRs) leaflet.

IFR contact information

Individual Funding Request Team
Floor 3F, Kingston House
438 High Street
West Bromwich
West Midlands
B70 9LD

Telephone: 0121 611 0470

Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Additional IFR contact information is available.

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.

Other existing local CCG policies

Treatment policy Category Treatment policy detail Patient treatment decision aid
Assisted conception Restricted             Assisted conception   
Bariatric surgery Restricted              Bariatric surgery   
Carpal tunnel Restricted              Carpal tunnel  Carpal tunnel syndrome 
Complementary therapies and alternative medicines Not routinely commissioned Complementary therapies and alternative medicines    
Diagnostic arthroscopy of the knee joint Not routinely commissioned Diagnostic arthroscopy of the knee joint   
Facet joint and epidural injections Restricted              Facet joint and epidural injections    
Port wine stain Not routinely commissioned    
Rosecea – laser treatment Not routinely commissioned    
Planned caesarean section Restricted - RCOG guidelines   Birth options after previous c-section 
Laser treatment for myopia (keratoplasty) Not routinely commissioned    
Dupuytren contracture Restricted Dupuytren contracture   
Reversal of male and female sterilisation (including vasectomies) Not routinely commissioned    
Any treatment purporting to treat allergy as a cause of chronic (post-viral) fatigue syndrome Not routinely commissioned    
Treatment of myalgic encephalomyelitis Not routinely commissioned    
Any treatment of candida hypersensitivity syndrome Not routinely commissioned    
Radiotherapy for age-related macular degeneration of the eye Not routinely commissioned    
Nucleoplasty (percutaneous coblation disc herniation) Not routinely commissioned    
Arthroscopic washout Not routinely commissioned    
Use of dilators or microwaves for benign prostatic hyperplasia Not routinely commissioned    
Use of lithiotripsy to treat small asymptomatic renal calculi Not routinely commissioned    
Congenital vascular abnormalities Restricted    
Photodynamic therapy Restricted    
Surgical removal of mucoid cysts at DIP joint Restricted    
NIV & CPAP cachine Restricted    
Hyperbaric oxygen therapy Restricted    
Removal of ear wax Restricted (established primary care pathway in Solihull)    
Allergy testing Restricted    
Acupuncture Restricted    
Carotid artery surgery for asymptomatic patients with carotid artery disease Restricted    
Botulinum toxin for facial ageing Not routinely commissioned    
Non-emergency patient transport Restricted

NEPT - Patient Charter and Eligibility Criteria 

NEPT 

 
Dilation of cervix   Dilation of cervix uteri curettage of uterus   

Phase 2 - next steps

Following the 2013-2017 program to develop an initial harmonised set of 21 treatment policies, which can be found within the policies folder, the following Clinical Commissioning Groups (CCGs) have maintained their collaborative partnership and are currently developing an additional 22 treatment policies:

  • Birmingham and Solihull CCG (formerly Birmingham CrossCity, Birmingham South Central and Solihull CCGs)
  • Sandwell & West Birmingham CCG.

Programme aims 

In line with the original Phase 1 Policy Harmonisation – the programme aims 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.

Programme structure

Engagement and policy sign-off Public/provider/professional engagement is planned for May-June 2018 and will build on the initial clinical engagement and see a number of public engagement initiatives undertaken, including community events to ensure the maximum exposure of the drafted policies. The public will have the opportunity to comment and provide feedback. After the conclusion of this phase, the TPCDG will meet again in July-August 2018 to review the collective feedback and collectively agree the phase 2 updated suite of treatment policy as well as writing and signing off the final engagement report. The policy will be submitted to the respective CCG Boards following for their sign-off in August-September 2018. Evidence Reviews linked to the various policies and used by the Treatment Policy Clinical Development Group can be found here

Phase 2 Treatment Policy List

  1. Acupuncture for indications (other than back pain which is proscribed in NICE NG59)
  2. Assisted conception
  3. Breast implant revision surgery
  4. Carpal tunnel surgery policy and leaflet
  5. Complimentary therapies and alternative medicines
  6. Cough assisted machines
  7. Dupuytren contracture policy (with/without Xiapex injections) and leaflet
  8. Ear wax
  9. Hip arthroscopy policy and leaflet
  10. Investigation of painless rectal bleeding
  11. Knee washout/debridement and diagnostic and surgical arthroscopy of the knee joint policy and leaflet
  12. Lithotripsy to treat small asymptomatic renal calculi
  13. Port wine stain progression
  14. Provision of NHS-funded gamete retrieval and cryopreservation
  15. Reversal of male sterilisation
  16. Reversal of female sterilisation
  17. Standing and open MRI
  18. Surgery for asymptomatic/symptomatic bunions and hallux valgus
  19. Treatment for ME (including inpatient, graded exercise and CBT)
  20. Treatment for snoring: uvulopalato and uvulopalatopharyngoplasty; palate implants; and radiofrequency ablation of soft palate
  21. Umbilical and para-umbilical hernia (including laparoscopic approach)
  22. Vasectomy – local and general anaesthetic.

Phase 2 - engagement

Find out more here.

Supporting patients and clinicians in Shared Decision Making