This involvement exercise has now closed.
We're continuing our review of clinical policies in stages to reduce differences in access to healthcare services in the Black Country.
- stage 1 concluded on 28 February 2024
- stage 2 concluded on 19 March 2024 - an involvement report detailing the findings is being developed and will be shared here soon.
- further involvement will be carried out over the coming months for the remaining clinical policies.
All views gathered in this public involvement exercise will be used to inform our final decision-making on these policies.
In July 2022, a change in the law created our new organisation, NHS Black Country Integrated Care Board (ICB), to take over local healthcare planning from the former clinical commissioning group (CCG) serving the areas of Dudley, Sandwell, Walsall, and Wolverhampton.
Since the ICB establishment we have been reviewing our clinical policies. This includes:
- reviewing the four existing CCG policies to harmonise them into one new position for the ICB
- implementing new policies to consider national clinical guidelines and best practice
- medical or surgical interventions, tests and treatments that do not have a clinical commissioning policy.
While the majority of their clinical policies were similar, there were several clinical polices that had some differences. To address these differences, commissioning policies for treatments listed below are being reviewed to look at how they can be made the same for the places of Dudley, Sandwell, Walsall, and Wolverhampton.
Clinical experts have looked at the latest evidence and practice for all of these services, both nationally and locally, to ensure the local offer is high quality and safe.
The clinical policy review will continue in stages.
A further public involvement exercise took place in March 2024 to collect wider views and feedback from local people and staff to inform our final decision-making. An involvement report detailing the findings is being developed and will be shared here soon.
Each proposed policy is listed below, along with details of the proposed changes and the new proposed policy.
For reference when you see NICE, we refer to the National Institute for Health and Care Excellence and EBI stands for evidence-based interventions which is the national policy position.
Proposed clinical policy harmonisation
This is a harmonised policy.
The proposed policy states:
The ICB will fund inguinal hernia repair for:
- Children under the age of 18 years.
- Indirect inguinal hernia in natal females (Natal women presenting with suspected indirect inguinal hernia should be referred for urgent assessment).
- Patients with strangulated or obstructed inguinal hernias.
- Patients with irreducible and partially reducible inguinal hernias.
- Patients who experience pain or discomfort that limits daily activities.
- Patients who are undergoing or plan to undergo peritoneal dialysis.
See the proposed Hernias inguinal policy.
Is there a proposed change?
No change. There is more clarity that females (at birth-natal) should be referred urgently. This policy also aligns with the EBI national guidance.
This is a harmonised policy.
The proposed policy states:
Cholecystectomy is not routinely commissioned for asymptomatic patients and will only be funded if the patient meets the eligibility criteria below.
- Cholecystectomy is not routinely commissioned for asymptomatic gallstones. Where gallstones are an incidental finding, asymptomatic is defined as symptom free for the 12 months before the diagnosis.
- Cholecystectomy will be funded for individuals who:
- have been managed conservatively and subsequently developed symptoms, and who have haemolytic conditions (e.g. sickle cell, thalassemia) or received a transplant or cirrhosis of the liver.
- have had a confirmed episode of gallstone induced pancreatitis.
- have had a clinical diagnosis of cholecystitis.
- have had an episode of obstructive jaundice caused by biliary calculi.
- have a history of biliary colic.
- have a bile duct stone.
See the proposed Cholecystectomy policy.
Is there a proposed change?
No change for asymptomatic. There is a change to the high risk group to include haemolytic conditions and additional criteria of biliary colic for all places and increasing access. The policy aligns with the EBI national guidance and NICE guidelines.
This is a new policy.
The proposed policy states that:
The Black Country ICB will not routinely fund MRI scan of the hip within primary care to diagnose osteoarthritis.
The Black Country ICB will fund MRI scan of the hip when there are concerns that there are other causes for the patient’s symptoms.
An MRI of the hip will be funded in any of the following circumstances (whether the patient has suspected or confirmed osteoarthritis of the hip or not):
- There has been trauma to the hip and there is worsening of symptoms.
- The patient has a history of cancer or corresponding risk factors and there is a suspicion that bone metastases might explain the patient’s symptoms.
- An infection is suspected.
- There is a suggesting of mechanical, impingement type symptoms.
- Prolonged / morning stiffness particularly if there is a family history of inflammatory arthropathies.
- When osteonecrosis / avascular necrosis of the hip is suspected.
- When transient osteoporosis is suspected.
- When periarticular soft tissue pathology e.g., abductor tendinopathy is suspected.
Is there a proposed change?
This is a new policy for Dudley, Sandwell, Walsall and Wolverhampton which aligns with the EBI national guidance and NICE guidelines.
This is a new policy.
The proposed policy states that Helmet therapy for the treatment of positional plagiocephaly/brachycephaly in children is not funded on the grounds that there is no evidence of benefit.
Is there a proposed change?
This is a new policy for Dudley, Sandwell, Walsall and Wolverhampton which aligns with the EBI national guidance.
This is a new policy.
The proposed policy states:
Diagnostic imaging (plain radiograph, weight bearing plain radiography, MRI scan) is not funded to confirm osteoarthritis in the knee in individuals who:
- Are 45 or over and
- Have activity-related joint pain and
- Have either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.
Where osteoarthritis is suspected but the patient is a younger adult, then a weight bearing plain radiography is the imagining of choice. MRI as second line diagnostic imaging will be funded:
- In patients who have severe symptoms but relatively mild OA on standard X-rays.
- In working up a patient for possible partial or total HTO (High Tibial Osteotomy) or partial knee replacement.
An MRI of the knee will be funded in any of the following circumstances (whether the patient has suspected or confirmed osteoarthritis of the knee or not):
- There has been trauma to the knee and there is worsening of symptoms.
- The patient has a history of cancer or corresponding risk factors and there is a suspicion that bone metastases might explain the patient’s symptoms.
- An infection is suspected.
- There is a suggesting of mechanical, impingement type symptoms.
- Prolonged / morning stiffness particularly if there is a family history of inflammatory arthropathies.
- When osteonecrosis / avascular necrosis of the knee is suspected
- When transient osteoporosis is suspected
- When periarticular soft tissue pathology e.g., abductor tendinopathy is suspected.
Is there a proposed change?
This is a newly implemented policy for Dudley, Sandwell, Walsall and Wolverhampton, and it reflects the current local referral pathway. The policy also aligns with the EBI national guidance.
This is a new policy.
The proposed policy states:
An MRI of the knee can be requested for the investigation of a possible meniscal tear when:
- The patient has a locked knee.
- The patient has persistent mechanical knee symptoms and is being referred to secondary care for investigation.
- When an individual with an acute injury has been referred for a possible arthroscopy.
Is there a proposed change?
This is a newly implemented policy for Dudley, Sandwell, Walsall and Wolverhampton, and it reflects the current local referral pathway. The policy also aligns with the EBI national guidance.
An involvement report detailing the findings is being developed and will be shared here soon.
Medical or surgical interventions, tests and treatments
There is no clinical commissioning policy for the below interventions, tests and treatments, instead, we are following the guidance from the evidence-based interventions programme. This includes:
- Blood transfusion
A procedure in which a patient intravenously (a drip through a vein) receives blood from a healthy donor, usually during surgery or for other medical conditions. - Liver function, creatinine kinase and lipid level tests (Lipid lowering therapy)
A liver function test is a blood test to assess how well the liver is working. A creatinine Kinase test measures an enzyme in the body that is responsible for healthy muscle function. Lipid tests measures the amount of certain fat molecules called lipids in your blood and are used to assess your cardiovascular health. - Pre-operative chest x-ray
A quick and painless procedure commonly used to produce images of the inside of the chest before surgery. - Pre-operative Electrocardiogram (ECG)
A test which records the rhythm, rate and electrical activity of your heart before surgery. - Surgical Intervention for Benign Prostatic Hyperplasia (BPH)
A condition where, as people with a prostate grow older, the prostate gland becomes larger. It can cause urinary symptoms, and in a small number of cases surgery maybe needed. - Troponin tests
A blood test used to measure any damage to heart muscle. - Vertebral augmentation for painful Osteoporotic vertebral fractures
A procedure which involves the injection of bone cement into a spinal fracture via a needle inserted through the skin, using camera guidance. The procedure aims to increase stability and strengthen the bone, also reducing pain and further collapse. - Surgical removal of kidney stones
Kidney stones are products of waste in the blood that can occasionally form crystals, over time the crystals may build up to form a hard stone-like lump. - Prostate specific antigen (PSA) test
A blood test to measure the protein called prostate specific antigen. - Cystoscopy for uncomplicated lower urinary tract symptoms
A procedure using a thin telescope to look at the lining of the bladder. - Diagnostic coronary angiography for low risk, stable chest pain
A coronary angioplasty is a procedure used to widen blocked or narrowed coronary arteries (the main blood vessels supplying the heart). - Exercise ECG (Electrocardiogram) for screening for Coronary Heart Disease (CHD) - outpatients
Common test looking at how your heart works when you’re exercising, maybe used to find out if Coronary Heart Disease is present. - Appendicectomy without confirmation of appendicitis
Surgery to remove the appendix. - Upper GI (gastrointestinal) endoscopy - inpatients
A routine test using a long thin tube with a small camera (called an endoscope) is passed via the mouth to examine the Oesophagus (food pipe), stomach and part of the small intestines. - Upper GI (gastrointestinal) endoscopy - outpatients
A routine test using a long, thin tube with a small camera (called an endoscope) which is passed via the mouth to examine the Oesophagus (food pipe), stomach and part of the small intestines. - Early endoscopic retrograde ERCP (Endoscopic retrograde cholangiopancreatography) in acute gallstone pancreatitis without cholangitis
Endoscopic retrograde Cholangiopancreatography, a procedure using x-rays and a gastroscope to look at the bile and pancreatic duct. - Appropriate colonoscopy in the management of hereditary colorectal cancer - inpatients
A colonoscopy is a routine test to examine the lining of your bowel, also called the large intestine or colon. Routine testing is a day case, to screen people who have a family history of colorectal cancer. - Appropriate colonoscopy in the management of hereditary colorectal cancer - outpatients
A colonoscopy is a routine test to examine the lining of your bowel, also called the large intestine or colon. Routine testing is a day case, to screen people who have a family history of colorectal cancer. - Repeat colonoscopy
A colonoscopy is a routine test to examine the lining of your bowel, also called the large intestine or colon.
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
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.
Cardiovascular disease
Diagnostic coronary angiography for low risk, stable chest pain
Exercise electrocardiogram (ECG) for screening for coronary heart disease
Liver function, creatinine kinase and lipid level tests (Lipid lowering therapy)
Gastrointestinal disease
Appendicectomy without confirmation of appendicitis
Appropriate colonoscopy in the management of hereditary colorectal cancer
Haematology
Kidney disease & urology
Surgical intervention for benign prostatic hyperplasia (BPH)
Cystoscopy for uncomplicated lower urinary tract symptoms
Prostate-specific antigen (PSA) test
Surgical removal of kidney stones
Musculoskeletal / Spine
Vertebral augmentation for painful osteoporotic vertebral fractures
Pre-operative assessment
An involvement report detailing the findings is being developed and will be shared here soon.
