Since 2013 the following clinical commissioning groups (CCGs) and 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
The aim has been 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 Sandwell (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:
- Final engagement report
- Harmonised Treatment Policies Equality Assessment report
- Glossary of Terms for Treatment Policies
- Treatment Policies
- Treatment Policies Activity Trends 2018-19
The following Clinical Commissioning Groups (CCGs) have maintained their collaborative partnership and have developed an additional 22 treatment policies:
- Birmingham and Solihull CCG (formerly Birmingham CrossCity, Birmingham South Central and Solihull CCGs)
- Sandwell & West Birmingham CCG.
Public/provider/professional engagement took place from May-June 2018, building on the initial clinical engagement and saw a number of public engagement initiatives undertaken, including community events to ensure the maximum exposure of the drafted policies. The public had the opportunity to comment and provide feedback.
That feedback was fully reviewed and a number of changes to the draft policies were made. This is summarised in:
- Full engagement report
- You said, we did reports (see Treatment Policies: May to June 2018)
- Treatment Policies
- Clinical Treatment Policies equality impact assessment report
- Treatment Policies Activity Trends 2018-19
The revised policies were submitted to the respective CCG boards for their sign-off, and went before Birmingham and Solihull CCG’s Governing Body in October 2018.
- Assisted conception
- Breast correction surgery (Mastopexy)
- Breast implant revision
- Carpal Tunnel Syndrome
- Chronic Fatigue Syndrome
- Dupuytren's Contrcture
- Eyelid surgery
- Face lift or brow lift
- Gamete retrieval
- Groin hernia repair
- Hair removal or depilation
- Hip arthroscopy
- Hip replacement surgery
- Hysterectomy for heavy menstrual bleeding
- Kidney stones
- Knee replacement surgery
- Labia reduction
- Low back pain/radicular pain
- Male circumcision
- Medical removal of scars
- Nose correction
- Port wine stains
- Rectal bleeding
- Removal of lipomata
- Removal of skin lesions
- Surgical removal of piles
- Trigger finger
- Varicose veins
- Viral warts
Not normally funded procedures
- Botox injections
- Breast augmentation
- Breast reduction cosmetic surgery
- Chemical peel
- Complementary and alternative therapies
- Ear pinning surgery
- Earlobe surgery
- Enlarged male breasts
- Excessive sweating (Hyperhidrosis)
- Gall bladder removal surgery (Cholecystecotomy)
- Hysteroscopy heavy periods
- Inverted nipples
- Knee arthroscopy
- Other cosmetic procedures
- Reversal of female sterilisation
- Reversal of male sterilisation
- Revision of previous cosmetic surgery
- Swelling of the nose (Rhinophyma)
- Tattoo removal
- Thigh lift, buttock lift and arm lift, removal of redundant skin or fat
- Thread or spider veins
- Treatment for heavy periods (Menorrhagia)
- Tummy tuck
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 Sandwell 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.
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
Telephone: 0121 611 0470
Additional IFR contact information is available.
Find out more
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.
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 smoking cessation and weight reduction management services prior to surgery where commissioned.
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.
Supporting patients and clinicians in Shared Decision Making
View the Supporting Patients and Clinicians in Shared Decision Making page.