Clinical policy review (4)

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

The proposed policy states that:

The ICB will fund hernia repair for:

• Young children when the hernia has not resolved spontaneously within the expected timeframes.
• Patients with strangulated or obstructed hernias.
• Patients who experience pain or discomfort that limit daily activities.
• Patients who are undergoing or plan to undergo peritoneal dialysis.
• Patients who need repair prior to undergoing other surgery where the presence of a hernia creates other clinical problems (e.g. colostomy).

View proposed Abdominal hernia repair policy

Is there a proposed change?

The new criteria will result in a widened scope for Dudley and Walsall as there was no previous policy. There is widened access for Sandwell and Wolverhampton for young children where it doesn't resolve spontaneously and additional access in Sandwell for patients undergoing peritoneal dialysis.

This is a new policy for Dudley, Walsall and Wolverhampton. There is no change for Sandwell.

Definition of 'Acupuncture for tension headaches':

Acupuncture is a treatment derived from ancient Chinese medicine where fine needles are inserted at certain sites in the body for therapeutic or preventative purposes. A tension-type headache is the most common type of headache and the one we think of as a normal everyday headache.

The proposed policy states that:

The ICB will commission a course of up to 10 sessions of prophylactic acupuncture over 5–8 weeks for chronic tension-type headaches, for patients who meet the following criteria:

• The patient must be diagnosed with chronic tension type headaches.
• The patient must have tension headaches on 15 days per month or more, on average, and having the following characteristics:
  • Lasting hours to days, or unremitting.
  • At least two of bilateral location; pressing or tightening (non-pulsating) quality;
    • mild or moderate intensity; not aggravated by routine physical activity such as walking or climbing stairs.
  • No moderate or severe nausea or vomiting and no more than one of photophobia or phonophobia.
  • Not better accounted for by another cause.
• A repeat course will be funded following a minimal time interval of 12 months from the previous final session. Repeat courses will be based on the clinical judgement of the treating clinician

View proposed Acupuncture for tension headaches policy

Is there a proposed change?

This is a new policy for Dudley, Walsall and Wolverhampton. Change for Sandwell is the addition of a timeframe for repeated treatment.

This is a new policy for Dudley, Walsall and Wolverhampton, and an updated criteria for Sandwell.

The proposed policy states that:

• The ICB will commission up to 10 sessions of prophylactic acupuncture over 5–8 weeks for migraine with or without aura if both topiramate and propranolol are unsuitable or ineffective. 
• A repeat course will be funded following a minimal time interval of 12 months from the previous final session. Repeat courses will be based on the clinical judgement of the treating clinician.

View proposed Acupuncture for migraines policy

Is there a proposed change?

This is a new policy for Dudley, Walsall, and Wolverhampton. Change for Sandwell is the addition of a timeframe for repeated treatment.

This is a new policy for Dudley, Walsall and Wolverhampton, and there is no change for Sandwell.

The proposed policy states that:

• Biological and biosynthetic meshes for standard hernia repair (all types - inguinal; femoral; umbilical, para-umbilical and incisional) are not routinely commissioned.
• Biological and biosynthetic meshes will be funded when the patient meets the following criteria:
  • When the patient has had first line hernia repair surgery with a permanent synthetic mesh followed by conservative wound care management that has failed, OR
  • When it is deemed clinical inappropriate to use a permanent synthetic mesh for first line hernia repair followed by conservative wound care management.
• In all instances the patient must have been reviewed by a specialist complex abdominal wall repair multi-disciplinary team and the use of biological/ iosynthetic mesh must be deemed the most clinically appropriate surgical intervention by a complex abdominal wall repair MDT.
• Surgery will only be funded where surgery is performed by surgeons trained in complex abdominal wall repair.

For the purposes of this policy, conservative wound care management is defined as a wound care management plan, developed for the individual patient by the specialist wound care management team that has failed.

View proposed Biological and biosynthetic meshes in hernia repair policy

Is there a proposed change?

This is a new policy for Dudley, Walsall and Wolverhampton and there is no change for Sandwell.

This is a new policy for Dudley and Wolverhampton and there is no change for Walsall and Sandwell.

The proposed policy states that:

1. Surgery will not routinely be funded for individuals that have asymptomatic deformities. Funding will not be supported for referrals to secondary care for patients who are asymptomatic and wish for surgical repair on aesthetic grounds.
2. Patients with symptomatic bunions should be treated conservatively and referred to local podiatry services unless:
   • They are a diabetic patient, in which case they should be reviewed within the diabetic service.
   • There are signs of tissue damage such as a non-healing foot ulcer or suspected peripheral limb ischaemia, in which case an urgent referral should be made to the relevant specialist service.
3. Referral to secondary care and surgery, if recommended, is funded to correct the deformity, for patients who have one or more of the following:
   • Significant symptoms that have not resolved with 3 months of conservative management
   • Progressive symptoms and deformity
   • The individual is not able to find comfortable well fitted footwear
   • The second toe has become involved
   • The individual has mobility problems such as balance, restricted walking and falls because of the bunion
4. Surgical correction of hallux valgus using minimal access techniques
   • Surgical correction of hallux valgus using minimal access techniques is considered experimental and will not be funded by the ICB outside of a formal clinical study.

View proposed Surgery for bunions (Hallux Valgus) policy

Is there a proposed change?

This is a new policy for Dudley and Wolverhampton and there is no change for Walsall and Sandwell.

This is a harmonised policy.

The proposed policy states that cataracts eye surgery is commissioned for both first and second eyes, when a patient meets one or more of the following criteria for each eye:

• The patient’s vision and quality of life is affected, for example the patient has difficulty carrying out everyday tasks such as recognising faces, watching TV, cooking, playing sport/cards etc.

OR

• The patient’s vision has resulted in reduced mobility, reduced ability to drive, or is experiencing difficulty with steps or uneven ground.

OR

• The patient’s vision has resulted in reduced ability to work, give care or live independently.

AND

• The patient must accept and want cataract surgery.

This information together with a report from a recent sight test should form the minimum data on the referral form.

The ICB will also fund cataract surgery if the patient has ONE of the following diagnoses that requires cataract surgery with OR without the above-mentioned visual symptoms;

• Monitoring posterior segment disease e.g. diabetic retinopathy
• Correcting anisometropia
• Patient with Glaucoma who require cataracts surgery to contract intraocular pressure

Patients with Single Sight (Monocular Vision):

The indications for cataract surgery in patients with monocular vision and those with severe reduction in one eye e.g. dense amblyopia are the same as for patients with binocular vision, but the ophthalmologist should explain the possibility of total blindness if severe complications occur.

View proposed Policy for cataracts policy

Is there a proposed change?

The requirement for visual acuity criteria and eye test reports have been removed in Dudley, Walsall and Wolverhampton. This is in line with national recommendations. No change for Sandwell.

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

The proposed policy states that the ICB will commission surgical intervention for chronic rhinosinusitis if the patient meets the eligibility criteria below.

1. Patients are eligible to be referred for specialist secondary care assessment in any of the following circumstances:

• A clinical diagnosis of chronic rhinosinusitis in primary care and patient still has moderate/ severe symptoms after a 3-month trial of intranasal steroids and nasal saline irrigation;

AND

• In addition, for patients with bilateral nasal polyps there has been no improvement in symptoms 4 weeks after a trial of 5-10 days of oral steroids (0.5mg/kg to a max of 60 mg); OR,
• The patient has nasal symptoms with an unclear diagnosis in primary care;

OR

• The patient has unilateral symptoms or clinical findings, orbital, or neurological features should be referred urgently via the cancer pathway.

Note: No investigations, apart from clinical assessment, should take place in primary care or be a pre-requisite for referral to secondary care.

There is no role for prolonged courses of antibiotics in primary care.

2.Endoscopic surgery will be funded when the following clinical criteria are met:

• A standardised scoring tool of disease-specific symptom patient reported outcome measure confirms moderate to severe symptoms (e.g., The Sinonasal Outcome Test (SNOT-22)) after trial of appropriate medical therapy (including counselling on technique and compliance).

3. There are a number of medical conditions whereby endoscopic sinus surgery may be required outside the above criteria and in these cases, they should not be subjected to the above criteria and continue to be routinely funded.

• Emergency presentations with complications of sinusitis (for example when there is an orbital, subdural or intracranial abscess).
• Patients with immunodeficiency
• When fungal sinusitis is suspected or confirmed
• Patients with conditions such as Primary Ciliary Dyskinesia, Cystic Fibrosis or NSAID-Eosinophilic Respiratory Disease (NSAID-ERD, Samter’s Triad Aspirin Sensitivity, Asthma, chronic rhinosinusitis)
• When treatment with topical and/or oral steroids is contra-indicated.

View the proposed Surgical intervention for Chronic Rhinosinusitis policy

Is there a proposed change?

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

This is a harmonised policy.

The proposed policy states that: 

1. Continuous positive airway pressure (CPAP) is routinely commissioned for:
   • Adults with moderate or severe symptomatic obstructive sleep apnoea/hypopnoea syndrome (OSAHS) 
2. Adults with mild OSAHS if:
   • The OSAHS is affecting their quality of life and usual daytime activities, AND
   • Lifestyle advice alone and any other relevant treatment options have been unsuccessful or are considered inappropriate.
3. For people with mild OSAHS having CPAP, telemonitoring with CPAP will be funded for up to 12 months.
4. Auto‑CPAP will be funded instead of fixed-level CPAP for people with moderate or severe OSAHS if:
   • high pressure is needed only for certain times during sleep or
   • they are unable to tolerate fixed-level CPAP or
   • telemonitoring cannot be used for technological reasons or
   • auto‑CPAP is available at the same or lower cost than fixed-level CPAP, and this price is guaranteed for an extended period of time.

The diagnosis and treatment of OSAHS, and the monitoring of the response, should always be carried out by a specialist service with appropriately trained medical and support staff.

Mild OSAHS = Apnoea Hypopnoea Index (AHI) is between 5 to <15

Moderate OSAHS = AHI is between 15 to <30

Severe OSAHS = AHI is ≥ 30

Exclusion criteria:

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

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

• One CPAP machine
• 1-2 lengths of tubing per year
• 1-2 masks per year

In a small proportion of OSA patients, CPAP proves insufficient to control apnoea and it becomes necessary to use Bi-level NIV. If a patient has failed treatment with CPAP, but continues to meet the eligibility criteria outlined above, a further funding application will be considered for:

• One Bi-level NIV machine
• 1-2 lengths of tubing per year
• 1-2 masks per year

View the proposed Policy for the use of domiciliary continuous positive airway pressure devices (CPAP) policy.

Is there a proposed change?

New policy for Dudley, Walsall and Wolverhampton. No change to Sandwell.

This is a harmonised policy.

The proposed policy states that surgical treatment of haemorrhoids is commissioned in the following clinical circumstances:

• Recurrent grade 3 or grade 4 combined internal/external haemorrhoids with persistent pain or bleeding

OR

• Irreducible and large external haemorrhoid

View the proposed surgical treatment of Haemorrhoids policy.

Is there a proposed change?

There is more concise criteria wording for Dudley, Sandwell, Walsall and Wolverhampton policies.

This is a harmonised policy.

More information about Image guided high volume injections for Achilles tendinopathy:

Image guided high volume intra-articular injections or hydrodilatation is the procedure of injecting a high volume of saline solution into the joint through an x-ray(fluoroscopy), ultrasound or computed tomography (CT). The solution may also contain some corticosteroid which contains some anaesthetic to provide quick pain relief and the steroid ‘cortisone’ to provide longer relief to ease pain and swelling.

The proposed policy states:

Image guided high volume injections for Achille’s tendinopathy will not routinely be commissioned on grounds that the treatment is currently experimental. Ongoing well designed clinical trials are needed.

Generally, when a treatment is considered experimental or unproven, the ICB will only fund treatments in the context of well-designed clinical trials through the ICB’s Research and Development Programme.

View the proposed Image Guided high volume injections for Achilles tendinopathy policy

Is there a proposed change?

There is no change for Dudley, Sandwell, Walsall or Wolverhampton.

This is a harmonised policy.

The proposed policy states that:

1. It is expected that intraarticular injections will be carried out, or initially attempted, with only use of vision and palpation to identify the injection point.
2. Guided intra-articular injections will only be funded when the patient’s general practitioner or consultant has had at least one failed attempt at injecting medicines into the joint; either because they are unable to find the correct route into the joint space or the injection is not hitting the correct mark.
3. Exceptions to this policy may be where the risks are higher if the therapeutic agent is not delivered into the correct space (for example radioisotopes).

View the proposed Image guided therapeutic and diagnostic intra-articular joint injections policy

Is there a proposed change?

Before using image guided injections there should be an attempt to inject into the joint.

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

The proposed policy states that implantable intraocular devices for ARMD are not funded on the grounds that they are experimental or unproven.

Generally, when a treatment is considered experimental or unproven, the ICB will only funded treatments in the context of well-designed clinical trials through the ICB’s Research and Development Programme.

View the proposed Policy for intraocular devices for end stage Age Related Macular Degeneration (AMRD) policy

Is there a proposed change?

This is a new policy for Dudley, Sandwell and Walsall. No change to Wolverhampton's policy.

This is a harmonised policy.

The proposed policy states that:

1. Female genitoplasty, including vaginoplasty, is routinely commissioned for a range of clinical conditions which include:

• Congenital malformation/absence or endocrine abnormalities of the vaginal canal.
• Repair of the vaginal canal after trauma (including obstetric trauma).
• Repair of pelvic organ collapse, protrusion of the bladder or colon into the vagina.
• Reconstruction following surgery treatment for cancer.

2. Cosmetic and aesthetic surgery is not routinely commissioned. This includes:

• Surgery to reduce the size of the labia minora (labiaplasty).
• Surgery to reduce the clitoral hood.
• Surgery to reduce the size of the labia majora (labia majoroplasty).
• Surgery to remove the excess fat of the mons (monsplasty).
• Vaginoplasty to tighten the vagina.
• Perineal refashioning to increase tone.
• Surgery to enhance the labia majora (labial puffing).

3.Gender reassignment surgery

• Vaginoplasty as part of gender reassignment surgery is currently the responsibility of NHS England.

4. Female Genital Mutilation (FGM) is illegal in the United Kingdom.

View the proposed Female genitoplasty (labiaplasty/vaginoplasty) policy

Is there a proposed change?

This is a harmonised policy for Dudley, Sandwell, Walsall and Wolverhampton including more specific criteria.

This is a harmonised policy.

The proposed policy states the following:

1. Congenital abnormalities

Congenital abnormalities of the ear can arise alone or as part of complex syndromes which may affect appearance, body function (such as deafness) or cognitive function.

• Surgery to correct microtia (small ear) or anotia (missing ear) or other malformations of the outer ear is routinely commissioned.
• The removal of an accessory auricle is not routinely commissioned; except as part of complex surgery to reconstruct an abnormal ear.
• Pinnaplasty for prominent ears is routinely commissioned for children and young people meeting the following criteria:
  •  Age ≥ 7 years to ≤ 18 years, AND
  • Prominent ear, upper 3rd mastoid – helical distance is ≥21.5 mm AND during the clinical assessment, a consultant surgeon is able to verify that the child is suffering from significant psychological distress due to their prominent ears.
  • The child and/or parents understand the risks and likely outcome and are motivated to proceed with surgery.

2. Variation in normal anatomy

• Outer ears come in a range of shapes and positions.
• Cosmetic and aesthetic surgery to change the shape of normal ears, including the earlobes is not routinely commissioned.
• Cosmetic and aesthetic surgery to reduce the size of the earlobe, including dropping because of the normal ageing process is not routinely commissioned.

3. Surgery to enable the wearing of hearing aids

• Otoplasty will be funded to enable children and adults to retain hearing aids or relieve pain particularly in those wearing their hearing aids during the night.

4. Elective surgical repairs to injured or damaged outer ears.

There are several injuries that can occur in the ear. These include traumatic human bites, split earlobes usually because of a tear caused by an earring or holes which have been purposefully created to accommodate large disc shaped earrings. An ear can also be partially damaged because of cancer.

• Surgical repair and reconstruction are routinely commissioned for major traumatic injuries to the ear involving the cartilage of the ear.
• Surgical excision and reconstruction are routinely commissioned for removal of cancers of the outer ear.
• Elective repair for minor traumatic injuries arising from earring tears is not routinely commissioned
• Reconstruction of earlobes damaged because of wearing earrings (including lobe stretching) is not routinely commissioned.

View the proposed Policy for surgery to reshape or repair the outer ear (Pinnaplasty and ear lobe surgery) policy.

Is there a proposed change?

There is a change to the age and specific eligibility criteria for Pinnaplasty, but there is no material change to ear lobe surgery.

The proposed policy states that procedures to treat scars and keloids are currently restricted.

Treatment of scars and keloids is commissioned in the following clinical circumstances:

• Severe post burn cases or severe traumatic scarring or severe post-surgical scarring, OR
• Revision surgery for scars following complications of surgery, keloid formation or other hypertrophic scar formation will only be commissioned where there is a significant deformity or to restore normal function.

View the proposed Removal of scars and keloids policy.

Is there a proposed change?

There is no change for Dudley, Sandwell and Walsall. For Wolverhampton, there is new criteria for severe post burn cases or severe traumatic scarring or severe post-surgical scarring. There is also new criteria for revision surgery for scars following complications of surgery.

This is a harmonised policy.

The proposed policy states the following: 

Interventional procedures for viral warts caused by Human Papillomavirus are commissioned in the following clinical circumstances:

1. Cutaneous viral warts

• Cutaneous viral warts are expected to be self-managed or treated in primary care. Treatment of warts in primary care is funded.
• Secondary care opinions or management are not routinely funded.
• Pre-agreed exceptions are where dermatology services contribute to the multidisciplinary team managing of other diseases, for example HIV.

2. Anogenital warts

• The treatment of anogenital warts is funded within the context of primary care or genitourinary medicine clinics
• Secondary care opinions or management are not routinely funded.
• Pre-agreed exceptions are:
  • Children
  • Where Gynaecology and Obstetrics and Urology clinicians contribute to the multidisciplinary team management of other diseases, for example HIV.

3. Epidermodysplasia verruciformis

• The ICB will fund hospital based interventional procedures as part of tertiary multi-disciplinary management of patients with genetic and acquired forms of epidermodysplasia verruciformis.

View the proposed Policy for interventional procedures for viral warts caused by Human Papilloma Virus (HPV).

Is there a proposed change?

There is a small change for Dudley, Sandwell and Walsall with an increase in the types of warts included if required specialist intervention. This is a new policy for Wolverhampton.

This is a harmonised policy.

The proposed policy states the following:

Surgery removal of haemangiomas commissioned in the following clinial circumstances:

1. The surgical removal or embolisation of internal haemangiomas at any age will be funded when recommended by the appropriate Multi-Disciplinary Team (MDT)

2. Superficial haemangiomas of childhood will not routinely be commissioned. Agreed exceptions are:

• The following when medical management has failed or not considered appropriate as sole or first line therapy:
  • Periorbital haemangiomas where they directly or indirectly (amblyopia) threaten vision.
  • Periauricular haemangiomas that obstruct the external auditory canal causing hearing impairment or repeat infection of the auditory canal.
  • Peri-nasal or columella haemangiomas causing significant destruction of the internal structures of the nose and potential for serious disfigurement.
  • Peri-oral or lip infantile haemangiomas resulting in mechanical feeding difficulties.
  • Subglottic and other upper airway haemangiomas when they threaten respiratory distress.
• Large facial haemangiomas that have failed to regress by school age.
• Ulceration and recurrent infection.
• If surgery is recommended by the vascular abnormalities MDT, removal will be funded.

3. Surgical facial reconstruction will be funded in rare instances where the haemangiomas has resulted in destruction of tissue (for example within the nose) or major scaring (usually nose and lip).

4. Removal of Pyogenic Granulomas will be funded.

5. The removal of cherry haemangiomas of adulthood will not be routinely funded unless there is uncertainty over the diagnosis, in which case excision biopsy will be funded.

View the proposed Surgical removal of haemangiomas policy.

Is there a proposed change?

This is a new policy for Dudley, Sandwell and Walsall. There is a new criteria for Wolverhampton which will widen access for causes of hearing impairment or mechanical feeding difficulty.