This is a new policy for Dudley and Walsall. Harmonised to Sandwell. New policy for Wolverhampton with concise criteria.

The proposed policy states:

• The patient pathway supporting this policy is attached in Appendix 1 of the policy linked below. 
• Arthroscopic surgery will be funded for individuals meeting the following clinical criteria: 
  • The patient is 45 years of age or under. Patients aged 46 to 55 may be considered if there are no signs of osteoarthritis. 
  • There is a definite diagnosis of femoroacetabular impingement (FAI) defined by appropriate imaging studies (X-rays, MRI or CT scans), showing labral pathology (e.g. partial or full thickness labral tearing or labral damage) with one or more of the following:
    • cam impingement (alpha angle greater than 50 degrees)
    • pincer impingement (acetabular retroversion or coxa profunda) (center edge angle greater than or equal to 40 degrees), or
    • pistol grip deformity (non-spherical femoral head shape); and
  • The patient has moderate to severe symptoms typical of FAI (hip or groin pain that is worsened by flexion activities such as squatting or prolonged sitting) that significantly limits activities and that has had a duration of at least six months; and
  • There is a positive impingement sign with sudden pain on 90-degree hip flexion with adduction and internal rotation or extension and external rotation; and
  • The patient has failed to respond to all available conservative treatment options including physiotherapy, activity modification (e.g., restriction of athletic pursuits and avoidance of symptomatic motion), pharmacological intervention (e.g., non-steroidal anti-inflammatory drugs) and, if needed, lifestyle advice. The treatment should have been delivered for at least 12 weeks in the previous 12 months with at least 6 weeks being formal physiotherapy (in-person with a licensed physical therapist); and
  • The pre-operative X-ray has no signs of osteoarthritis (Tönnis grade zero or severe cartilage injury, Outerbridge grade III or IV). Patients with Tönnis grade 1 can be referred for assessment as some may be suitable for surgery; and  
  • Joint space is not less than 2 mm wide anywhere along the sourcil; and
  • The patient has a BMI equal to or under 35; and
  • The patient does not have generalised joint laxity which affects the hip joints especially in diseases connected with hypermobility of the joints, such as Marfan syndrome and Ehlers-Danlos syndrome or osteogenesis imperfecta, unless referred by a consultant in rheumatology.
• Surgery will only be funded by the ICB when the following conditions are met:
  • Surgery is undertaken within a Specialist MDT Unit carrying out hip surgery for young people and younger adults supported by an MDT. (see Appendix 2). Consultants specialising in this area are expected to have had higher training for a minimum of 1 year and to be undertaking more than 50 procedures a year.   
  • The surgeon performing the procedure submits a dataset to the National Non-Arthroplasty Hip Register to ensure compliance with the requirement of the NHS to be able to trace an implanted device (where relevant) and to enable national level audit of this procedure. 

View proposed Hip arthroscopy for femoroacetabular impingement policy

Is there a proposed change?

New policy for Dudley and Walsall. No change for Sandwell. New policy for Wolverhampton previously not routinely commissioned. Now restricted with specific eligibility criteria with concise wording restricting procedure for specific patients.

This is a new policy for Dudley, Walsall and Wolverhampton. Harmonised for Sandwell.

The proposed policy states:

Abdominoplasty and apronectomy: Abdominoplasty is defined as the correction of anterior abdominal wall skin redundancy with undermining of flaps to allow repositioning of the umbilicus and application of the rectus abdominus muscles where indicated. Apronectomy is defined as amputation of an anterior abdominal skin fold with no undermining of the skin flaps and may include amputation of the umbilicus but no repositioning.

• Treatment will be funded following massive loss of excess weight (either as a result of bariatric surgery or through diet and exercise alone). Patients must meet the following criteria:
  • Patients should be over the age of 18 years and
  • A starting BMI of above 40Kg per m2  and
  • a current BMI of less than 30Kg per m2 and
  • maintained their weight for at least two years, both of which have been recorded and documented by a clinician in the patient's medical notes and
  • The patient’s skin redundancy must present a significant problem with daily living including any of the following criteria:
    • Significant mobility problems from skin redundancies that are likely to be significantly improved by body recontouring surgery.
    • The abdominal apron (overhang) descends beneath the symphysis pubis and partially obscures the genitalia and bilateral groin creases.
    • Documented evidence of suprapubic skin fold intertrigo, cellulitis, folliculitis, infection in the apron, skin ulceration, subcutaneous abscesses, fungal infections, and skin necrosis. These conditions must have been refractory from appropriate medical therapy for a period of at least six months.
    • The patient demonstrates functional restrictions in their ability to walk and ambulate due to the size of the apron.
• The patient has significant scars on the abdomen which may have associated hernia or pain, which are physically distressing and/or cause significant contour defects which present difficulties with hygiene and infection risk.
• Patients have problems associated with poorly fitting colostomy bags which may be improved with abdominal recontouring such as abdominoplasty or who need body contouring to enable a stoma to be fashioned. 
• Abdominoplasty / apronectomy is indicated as an essential surgery in order to complete a hernia repair or other abdominal wall surgical procedure.
• Surgery to remove unwanted fat for cosmetic or aesthetic (psychological) reasons is not routinely commissioned. 

Non-abdominal skin excisions for body contour (e.g., buttock, arm, thigh lift). Non-abdominal skin excisions for body concur will be routinely commissioned if the patient meets the criteria below:

• Patients should be over the age of 18 years and
• A starting BMI of above 40kg per m2  and 
• a current BMI of less than 30Kg per m2 and
• maintained their weight for at least two years, both of which have been recorded and documented by a clinician in the patient's medical notes and
• The patient’s skin redundancy must present a significant problem with daily living:
  • Documented evidence of skin fold intertrigo, cellulitis, folliculitis, skin ulceration, subcutaneous abscesses, fungal infections, and skin necrosis. These conditions must have been refractory from appropriate medical therapy for a period of at least six months.
  • The redundant skin/fat interferes significantly with the activities of daily living.
• Surgery to remove unwanted fat for cosmetic or aesthetic (psychological) reasons is not routinely commissioned. 
• Each patient will have access to funding for one course of surgical treatment to remove excess skin. All surgical interventions for removal of the excess skin must be undertaken as part of the original treatment plan and in line with the above eligibility criteria. Further applications for body contouring surgery will not be routinely funded and revision surgery to improve the cosmetic appearance will not be accepted. Funding is for surgical procedures to remove excess skin from an area of the body, which is causing severe functional problems or recurrent skin infections. 
• Patients should be informed smoking increases complications following surgery and should engage with smoking cessation programmes where appropriate.

View proposed policy for Body contouring

Is there a proposed change?

New policy for Dudley, Walsall and Wolverhampton. Harmonised for Sandwell with specific BMI criteria added.

This is a new policy for Dudley, Walsall and Wolverhampton. Harmonised to Sandwell legacy position.

The proposed policy states:

Policy for NIV in Chronic Obstructive Pulmonary Disease (COPD)
Chronic obstructive pulmonary disease (COPD) is the collective name for a group of lung conditions that may cause breathing difficulties. 
It includes: 

• emphysema – damage to the air sacs in the lungs 
• chronic bronchitis – long-term inflammation of the airways 

Eligibility criteria:
For patients with COPD the ICB will commission the use of domiciliary non-invasive ventilation in the following clinical circumstances: 

• The patient has a diagnosis of COPD, identified by post bronchodilator Forced Expiratory Volume (FEV)1 / Forced Vital Capacity (FVC) <0.70

and the patient must have ONE of the following:

• Failure to wean off NIV for patient admitted with Type 2 Respiratory Failure  
• 2-4 weeks post-acute admission the patient has a paCO2 over 7 kPa 
• Patient with COPD who are hypercapnic (paCO2>7kPa) and acidotic on long-term oxygen therapy. 
• Patient is symptomatic with hypercapnia or has co-existing sleep disorder breathing
• The patient has co-morbidities secondary to hypoxemia (pulmonary hypertension or heart failure) AND the patient has had recurrent NIV admissions (2 or more in a 12 month period) 

Exclusion criteria:

• Inability to remove mask independently (with no waking night carer) 
• Cognitive / behavioural limitation affecting ability to comply safely with NIV 
• Multiple co-morbidities limiting utility of NIV 

Funding will be provided for the following if the patient with COPD meets the above clinical criteria: 

• One NIV machine (with enabled remote monitoring ability)
• +/- Humidifier as required 
• 1-2 lengths of tubing per year 
• 1-2 masks per year 

Policy for NIV in Neuro-Muscular and Neurological weakness  
Several chronic neuromuscular disorders, for example muscular dystrophy and motor neurone disease lead to progressive respiratory muscle dysfunction, which in turn can lead to respiratory failure and death. Nocturnal and daytime Non-Invasive Ventilation (NIV) is the preferred method of treatment for these disorders. 

Non-invasive ventilation as a treatment for neuromuscular disease has several benefits. It has been shown to: 

• Improve lung mechanics and gas exchange 
• Decrease work of breathing 
• Improve symptoms of fatigue 
• Reduce daytime sleepiness 
• Improve survival in Duchenne Muscular Dystrophy (DMD) and Motor Neurone Disease (MND) patients. 

Eligibility criteria:

• Patients with one of the following conditions will be considered for funding when the patient also meets the eligibility criteria outlined below. 
• Motor Neurone Disease
• Muscular Dystrophies including Duchenne Muscular Dystrophy 
• Myotonic Dystrophy
• Spinal cord injury 
• Multiple Sclerosis 
• Guillain-Barre Syndrome 
• Post polio syndrome with respiratory impairment 
• Syringomyelia 
• Previous Tuberculosis infection with residual respiratory insufficiency 
• Diaphragmatic weakness
• Other neuromuscular impairment which is known to cause respiratory muscle weakness or upper airway functional impairment which are the commissioning responsibility of the ICB.

For patients diagnosed with a neuromuscular condition as outlined above, the patient must meet the following criteria for funding of non-invasive ventilation to be approved: 

Nocturnal ventilation - The patient must meet ONE of the following criteria: 

• Signs or symptoms of hypoventilation, or FVC <50% predicted/ or <1L
• MIP< 60cmH2O 
• A baseline SpO2 <95% 
• Elevated pCO2 whilst awake 
• Four or more episodes of SpO2 <92% 
• Drops in SpO2 of at least 4% per hour of sleep 

Daytime ventilation (in addition to meeting the above criteria the patient must also meet ONE of the following criteria): 

• Abnormal deglutition due to dyspnoea, which is relieved by ventilatory assistance 
• Inability to speak in full sentences without breathlessness 
• Symptoms of hypoventilation with baseline SpO2 <95% 
• Elevated pCO2 whilst awake
• Symptoms of awake dyspnoea are present 

Exclusion criteria:

• Inability to remove mask independently (with no waking night carer) 
• Cognitive / behavioural limitation affecting ability to comply safely with NIV 
• Multiple co-morbidities limiting utility of NIV 

Funding will be provided for the following if the patient meets the above clinical criteria: 

Below 14 hours of ventilation required. 

• One NIV machine (with enabled remote monitoring ability)
• +/- Humidifier as required 
• 1-2 lengths of tubing per year 
• 1-2 masks per year 

Above 14 hours / 24-hour period of ventilation required. 

• Two NIV machines (with enabled remote monitoring ability)
• +/- ONE Humidifier as required 
• 2-4 lengths of tubing per year 
• 2-4 masks per year 

NIV in Obesity hypoventilation syndrome
Obesity hypoventilation syndrome (OHS) is defined as the combination of obesity (body mass index (BMI) of 30 kg/m2 or more), raised arterial or arterialised capillary carbon dioxide (CO2) level when awake, and breathing abnormalities during sleep, which may consist of obstructive apnoea’s and hypopnea’s, or hypoventilation, or a combination of both. OHS is a specific form of chronic ventilatory failure.

Eligibility criteria:

• Patient has a Body Mass Index >30Kg/m2

Plus two of the following:

• Patient with evidence of chronic CO2 retention (who has a paCO2 more than 7 kPa AND/OR evidence of chronic CO2  retention with H CO3 >30)
• Overnight oximetry demonstrates that the patient meets the following criteria: 
  • Time spent below 90% SpO2 on air more than 30% of the sleep time 
  • Mean SpO2 below 90% on overnight oximetry 
• Hospital admission requiring Non-invasive ventilation for Acidotic Hypercapnic Respiratory Failure or inability to wean from nocturnal Non-invasive ventilation. 
• Clinical evidence of Cor-Pulmonale

Exclusion criteria:

• Inability to remove mask independently (with no waking night carer) 
• Cognitive / behavioural limitation affecting ability to comply safely with NIV 
• Multiple co-morbidities limiting the utility of NIV 

Funding will be provided for the following if the patient meets the above clinical criteria: 

Below 14 hours of ventilation required. 

• One NIV machine ( with enabled remote monitoring ability)
• +/- Humidifier as required 
• 1-2 lengths of tubing per year 
• 1-2 masks per year 

Above 14 hours / 24-hour period of ventilation required. 

• Two NIV machines (with enabled remote monitoring ability)
• +/- ONE Humidifier as required 
• 2-4 lengths of tubing per year 
• 2-4 masks per year

OHS with acute ventilatory failure

NB Offer non-invasive ventilation to people with OHS with acute ventilatory failure:

• If hypercapnia persists, consider continuing and further optimising non-invasive ventilation.
• If hypercapnia resolves, consider stopping non-invasive ventilation and monitoring the response.

After a person with OHS and acute ventilatory failure has been stabilised on non-invasive ventilation with control of hypercapnia, consider:

• stopping non-invasive ventilation and carrying out respiratory polygraphy and
• a trial of CPAP in people with frequent episodes of obstructive apnoea and minimal hypoventilation.

If the person decompensates after stopping non-invasive ventilation, offer to restart non-invasive ventilation.

Patients with OHS who do not have acute ventilatory failure

• Offer continuous positive airway pressure (CPAP) to people with OHS and severe OSAHS as first-line treatment.
• Offer non-invasive ventilation as an alternative to CPAP for people with OHS and severe OSAHS if symptoms do not improve, hypercapnia persists, apnoea–hypopnoea index (AHI) or oxygen desaturation index (ODI) are not sufficiently reduced or CPAP is poorly tolerated.
• Consider non-invasive ventilation for people with OHS and nocturnal hypoventilation who do not have OSAHS, or in whom OSAHS is not severe.

   NB: COPD–OSAHS overlap syndrome occurs in people who have both chronic obstructive disease (COPD) and obstructive sleep apnoea/hypopnoea syndrome (OSAHS). The combined effect of these conditions on ventilatory load, gas exchange, comorbidities and quality of life is greater than either condition alone.

• Consider continuous positive airway pressure (CPAP) as first-line treatment for people with COPD–  OSAHS overlap syndrome if they do not have severe hypercapnia (PaCO2 of 7.0 kPa or less).
• Consider non-invasive ventilation instead of CPAP for people with COPD–OSAHS overlap syndrome with nocturnal hypoventilation if they have severe hypercapnia (PaCO2 greater than 7.0 kPa).

NIV in Kyphoscoliosis and chest wall deformity 
Chest wall deformity and Kyphoscoliosis can cause restriction to the lung capacity and chronic hypercapnic respiratory failure. These patients benefit from the use of home NIV.

Eligibility criteria:

• Evidence of Chest wall deformity
• Chronic Hypercapnic respiratory failure

Exclusion criteria:

• Inability to remove mask independently (with no waking night carer) 
• Cognitive / behavioural limitation affecting ability to comply safely with NIV 
• Multiple co-morbidities limiting the utility of NIV

NIV in Central Sleep Apnoea
Central Sleep Apnoea (CSA) is characterized by repetitive cessation or decrease of both airflow and ventilatory effort during sleep. It can be primary idiopathic or secondary CSA associated with Cheyne-Stokes breathing, a medical condition, a drug or substance including opiates, or high-altitude periodic breathing.

CSA is further divided as hyperventilation- or hypoventilation-related. Hyperventilation associated CSA is due to most of the CSA mentioned as above. Hypoventilation-related

CSA happens with alveolar hypoventilation that is so severe that central apnoea’s occur when the patient falls asleep because the wakefulness stimulus to breathe disappears.

Eligibility criteria:

• A confirmed diagnosis of Central Sleep Apnoea with symptoms affecting QOL and sleep quality.
• Patients with hyperventilation-related Central Sleep Apnoea (CSA)- Continuous positive airway pressure (CPAP) is the preferred first-line therapy for symptomatic patients with hyperventilation-related CSA. For patients that failed to tolerate CPAP treatment decisions should be individualized based on the underlying aetiology of the CSA and individual patient characteristics.
• Patients with ejection fraction ≤40 percent — For patients with CSA due to heart failure with reduced ejection fraction (≤40 percent) who do not tolerate or respond to CPAP, the optimal approach is uncertain. Optimising medical therapy further to control heart failure remains the first line of treatment. Supplemental nocturnal oxygen can be considered to control CSA/CSR. If above interventions fail to make a difference to CSA; NIV (Bi-Level Positive Airway Pressure- Bi-PAP therapy) with a back-up rate may be the only available option for some patients.
• Patients with ejection fraction >40 percent — Patients with CSA and an ejection fraction >40 percent who fail or do not tolerate CPAP and have optimal control of underlying medical condition should be treated with NIV with Adaptive Sero Ventilation (dynamically adjusts pressure) or Bi-Level Positive airway pressure (fixed pressure) mode with a back-up respiratory rate.
• Patients with hypoventilation-related CSA- In patients with CSA whose central apnoea’s are due to hypoventilation, NIV (fixed pressure Bi-Level PAP- BiPAP) is the first-line therapy with or without a back-up respiratory rate.

Exclusion criteria:

• Inability to remove mask independently (with no waking night carer)
• Cognitive / behavioural limitation affecting ability to comply safely with NIV
• Multiple co-morbidities limiting the utility of NIV

Funding will be provided for the following if the patient with COPD meets the above clinical criteria:

• One NIV machine (with enabled remote monitoring ability)
• +/- Humidifier as required
• 1-2 lengths of tubing per year
• 1-2 masks per year

View the proposed policy for Use of domicillary non-invasive ventilation

Is there a proposed change?

New policy for Dudley, Walsall and Wolverhampton. Harmonised to Sandwell with specific BMI criteria added. 

Harmonised for Dudley, Wolverhampton, Sandwell and Walsall. 

The proposed policy states:

Secondary care management of varicose veins (which includes endovenous thermal ablation, ultrasound guided foam sclerotherapy or open surgery (ligation and stripping) will be funded for the following: 

• Varicose veins which bleed and are at risk of bleeding again (referral recommended to a vascular service) or
• A history of varicose ulceration or
• Signs of prolonged venous hypertension (haemasiderin pigmentation, eczema, induration lipodermatosclerosis) or 
• Superficial thrombophlebitis in association with varicose veins

If the patient has symptomatic varicose veins and does not meet the above criteria for surgical intervention, then consider advising compression hosiery.

View the proposed policy for Varicose veins

Is there a proposed change?

Removal of chronic venous insufficiency criteria for all places. Removal of significant oedema associated with skin changes for Sandwell and Wolverhampton and removal of symptomatic with pain/itching and heaviness etc... for Dudley and Walsall. Removal of symptomatic or recurrent varicose veins for Dudley, Sandwell and Walsall. Clarification on indication for compression hosiery. Criteria reworded to encompass engagement feedback.

This is a new policy for Wolverhampton. Harmonised for Sandwell, Walsall and Dudley.

The proposed policy states:

• Revision surgery for procedures that were undertaken through the private sector will not be routinely commissioned by the ICB.  
• Revision surgery following previous NHS cosmetic surgery is not routinely commissioned.
• In instances where the NHS has funded the procedure through the Individual Funding Request (IFR) route, revision surgery will also need to be applied for under the IFR process.    

View proposed policy Revision of cosmetic procedures

Is there a proposed change?

New policy for Wolverhampton. No change for Sandwell, Walsall and Dudley. Remains not routinely commissioned.

This is a new policy for Dudley and Wolverhampton. Harmonised for Sandwell and Walsall. 

The proposed policy states:

• Manual syringing to remove earwax is not funded.                                                                                                                                            
• Ear irrigation may be carried out in primary care by a specially qualified clinician in patients who have a level of understanding required to enable the procedure to be carried out safely in the following circumstances:
  • The patient must have used ear drops for at least 3-5 days before irrigation is undertaken and the patient must have at least one of the following symptoms which has persisted despite ear drops: 
    • Hearing loss
    • Earache
    • Tinnitus
    • Vertigo                        
• The person wears a hearing aid, and 
  • Need an impression to be taken for to fit another hearing aid; or 
  • The wax is causing the hearing aid to whistle.                                                                                                                              
• The tympanic membrane needs to be examined to establish a diagnosis but is obscured by wax.   

Ear irrigation as a management option for ear wax should be avoided whenever possible.

Referral should be arranged to an Ear, Nose, and Throat specialist if the person has:                                           

• A chronic perforation of the tympanic membrane
• A history of ear surgery
• A foreign body in the ear canal
• Used ear drops, which have been unsuccessful, and irrigation is contraindicated.
• Had unsuccessful irrigation.
• Eczema or psoriasis                                                                                                                                                                       

View proposed policy for Removal of ear wax

Is there a proposed change?

New policy for Dudley and Wolverhampton. No change for Sandwell. The proposed policy has concise wording with specific criteria for patients in a Primary Care setting. There is a change in timescales for the use of ear drops from Walsall legacy position. This has been reduced from 14 days to 3-5 days and two attempts at ear irrigation reduced to one attempt.

This is a new policy for Wolverhampton, harmonised for Dudley, Sandwell and Walsall.

The proposed policy states:

• Cosmetic surgery is not routinely commissioned by Black Country ICB.
• A list of examples of cosmetic interventions that are not commissioned is provided below. It should be noted, however, that this list is illustrative and not exhaustive.

Cosmetic breast surgery

• Cosmetic surgery of the nipple areolar complex

Cosmetic facial contouring surgery

• Alloplastic augmentation of the facial skeleton
• Bone grafting of the facial skeleton
• Free fat grafting to the face
• Genioplasty: sliding, reduction, lengthening and symmetrising 

Cosmetic surgery of the face

• Cosmetic facial contouring
• Platysmaplasty

Cosmetic surgery of the face/nose/periorbital region/ears

• Alloplastic augmentation of the facial skeleton
• Alloplastic facial augmentation
• Autologous fat transfer
• Bone grafting of the facial skeleton
• Facial contouring surgery
• Free fat grafting to the face
• Genioplasty
• Platysmaplasty
• Reconstructive facial recontouring or remodelling

Cosmetic body contouring surgery

• Cosmetic surgery of the hand
• Autologous fat transfer
• Body lift
• Gluteal augmentation
• Calf augmentation

Massive weight loss surgery (MWL) - Supplementary certificate in body contouring following massive weight loss

• Post bariatric surgery/MWL abdominoplasty
• Post bariatric surgery/MWL brachioplasty
• Post bariatric surgery/MWL autologous fat transfer
• Post bariatric surgery/MWL body lift
• Post bariatric surgery/MWL liposuction
• Post bariatric surgery/MWL thigh lift 

Other cosmetic surgery

• Repair of chronic clefts due to avulsion of body piercing.

The following list of procedures are covered by BCICB harmonised clinical policies , as indicated below.

Cosmetic breast surgery – Please see BCICB Breast Surgery Policy

• Augmentation mammoplasty
• Autologous fat transfer to breast for symmetrisation / augmentation
• Breast symmetrisation
• Correction of gynaecomastia
• Mastopexy
• Reduction mammoplasty

Cosmetic nasal surgery – Please see BCICB Rhinoplasty Policy

• Rhinoplasty

Cosmetic surgery of the periorbital region

• Brow lift – Please see BCICB Rhytidectomy Policy
• Midface lift - Please see BCICB Rhytidectomy Policy
• Upper lid blepharoplasty - Please see BCICB Eyelid Surgery Policy
• Lower lid blepharoplasty - Please see BCICB Eyelid surgery Policy

Cosmetic surgery of the ear

• Otoplasty - Please see BCICB Surgery to reshape or repair the out ear policy

Cosmetic surgery of the face

• Brow lift - Please see BCICB Rhytidectomy Policy
• Rhytidectomy - Please see BCICB Rhytidectomy Policy

Cosmetic surgery of the face/nose/periorbital region/ears

• Blepharoplasty - Please see BCICB Eyelid surgery Policy
• Brow Lift - Please see BCICB Rhytidectomy Policy
• Rhytidectomy - Please see BCICB Rhytidectomy Policy
• Midface lift - Please see BCICB Rhytidectomy Policy
• Otoplasty - Please see BCICB Surgery to reshape or repair the out ear policy
• Rhinoplasty - Please see BCICB Rhinoplasty Policy

Cosmetic body contouring surgery

• Abdominoplasty – Please see BCICB Body Contouring Policy
• Brachioplasty - Please see BCICB Body Contouring Policy
• Liposuction - Please see BCICB Liposuction Policy
• Thigh lift - Please see BCICB Body Contouring Policy.

View proposed policy Other cosmetic surgery

Is there a proposed change?

Signposting to new individual BC ICB harmonised policies. New policy for Wolverhampton. No change for Walsall, Sandwell and Wolverhampton. Confirming not routinely commissioned status.

This is a new policy for Dudley and Wolverhampton, harmonised for Walsall and Sandwell

The proposed policy states:

Open or Upright MRI, of at least 0.5Tesla is commissioning as an alternative to conventional MRI for: 

• Patients who are unable to tolerate conventional MRI due to claustrophobia despite conservative management of anxiety (including noise-cancelling headphones, visual aids and scanning feet first if possible) and the use of minimal sedation has been considered, and if clinically appropriate, offered. If sedation is not considered to be an appropriate option, the reason should be documented. or
• Patients who are obese and cannot fit comfortably in conventional MRI scanners as determined by a consultant radiologist or the providers Radiology department’s policy. or
• Patients who cannot lie properly in conventional MRI scanners because of severe symptoms, i.e. breathing difficulties or pain, despite adequate measures to reduces discomfort. or 
• Patients who require load bearing MRI images to be undertaken. This must be requested by a consultant/specialist. and 
• There is a clear diagnostic need consistent with supported clinical pathways.

In addition, The ICB will only fund an open or upright MRI of the specific anatomy that was in the original request and will not extend its use for other indications for that patient.  A new request will be required for each open or upright MRI

View the proposed Policy for the use of Upright/Open MRI (magnetic resonance imaging) Scanning 

Is there a proposed change? 

New policy for Dudley and Wolverhampton with restricted criteria. Clarified upright MRI wording for Walsall. Conservative management of anxiety/claustrophobia criteria added to compliment minimal sedation criteria (where clinically appropriate). No change to obese patient criteria, more concise wording for Upright MRI. No change for Sandwell load bearing MRI. Walsall Upright MRI criteria reworded for clarity, essentially the clinical intention has not changed.

This guidance was produced by The Academy of Medical Royal Colleges (the Academy) as part of the evidence-based interventions (EBI) programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE). 

The aims of the evidence based interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste. 

The Black Country ICB Clinical Policy Development Group (CPDG) have reviewed all guidance. They were reviewed to establish if existing CCG/ICB policies were already in place which covered the proposed intervention/treatment in question. 

Where there was no current legacy CCG policy for the area in question, the NHS England/Improvement (NHSEI) policy has been implemented in full. 

Where there was a current legacy CCG policy for the area in question, then the existing CCG policy has been reviewed by CPDG considering the NHSEI EBI policy rationale and evidence base. A decision has then been taken by CPDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population. 

Kidney disease & urology

Surgical intervention for bladder outflow obstruction

PSA testing for men aged 80 years and above

Musculoskeletal / Spine 

Scans for shoulder pain and guided injections for shoulder pain - EBI (aomrc.org.uk)

The evidence-based interventions (EBI) programme is an initiative led by the Academy of Medical Royal Colleges to improve the quality of care. The programme is supported by five partners: NHS England, NHS Confederation, the Patients Association, the National Institute for Health and Care Excellence (NICE) and Getting it Right First Time (GiRFT).

Created by both doctors and patients, as the name suggests, it is designed to reduce the number of medical or surgical interventions as well as some other tests and treatments which the evidence shows are inappropriate for some patients in some circumstances. In some instances, clinicians recommend we carry out more procedures because this will result in an improved quality of life for patients in the long term.

As well as improving outcomes it also means we can free up valuable resources so they can be put to better use elsewhere in the NHS. This is more important than ever as the NHS recovers from the impact of COVID-19 and restores services. We also know that sometimes these interventions can do more harm than good.

The EBI principles

The evidence-based interventions programme was developed in 2018 to help ensure a national approach to quality improvement and reduce unwarranted variation across the healthcare system.

Its key principles are to:

• improve the quality of care for everyone
• reduce the risk of harm to patients
• minimise unwarranted variation in service provision
• optimise the use of finite resources and ensure any money saved is spent on other, more effective treatments.

Read more information about the EBI programme from the Academy of Medical Royal Colleges