Revisions to Richmond CCG policies for *procedures of limited clinical effectiv​​en​​ess

CCGs periodically revise commissioning policies in light of new clinical evidence, updated clinical practice and improvements in technology. We do this to ensure that patients have access to the best possible treatments and procedures, in line with guidance from the *National Institute for Health and Care Excellence (NICE).

We are also obliged to constantly review the services, treatments and procedures that are funded as we have a statutory duty to remain within our allocated budget and to ensure best value for money, and the need to reduce costs informed our review. In reviewing these policies we have strived to make reductions which are in our clinical judgment of least detriment to patients.

The CCG’s governing body has recently reviewed our commissioning policies around a group of treatments called procedures of lesser clinical effectiveness (i.e. this is where there is still debate around the effectiveness of a particular procedure). We have worked with GPs and other clinical experts using clinical judgement, published scientific literature and data to find the best ways to spend the money we have. Changes to policies have focused on improving patient safety and clinical outcomes.

We have made changes to thresholds (i.e. referral criteria) on some procedures which have low effectiveness and / or potential harm to patients if done before adequate conservative treatment has been provided. This will improve access for patients to procedures which are proven to be more effective. We believe this will further improve equality of access to health services for local people as we will embed these revised policies in standard protocols and referral management systems.

The patient’s GP will have ultimate resp​onsibility for the individual patient and will use their clinical judgement in dealing with each individual patient’s circumstances and needs. Where necessary we already have a process to manage cases where there are exceptional circumstances which is called an​ Individual Funding Request route.

Below is a summary of the changes and revisions that have been made to the policies. 

Recent research indicates that evidence supporting surgical treatment for chronic knee pain is weak so we have introduced a stricter access threshold for the procedure, which is in line with *NICE guidelines. Non-surgical treatments should be offered for 12 months before surgery is considered. MRI scans are more effective as diagnostic examination of the knee rather than patients having arthroscopic knee surgery as a diagnostic procedure. The non-surgical options include physiotherapy, injections, anti-inflammatory drugs and exercises.​

​Dupuytren’s contracture has a tendency for aggressive progression and recurrence after surgical treatment in many patients. Hence surgery for mild Dupuytren’s will not normally be funded by the NHS. The policy was revised to provide clarity on the indications for surgical correction. There is evidence that alternative treatments offer better value for mild and moderate disease, such as splinting and steroid injections.​

Spinal pain is a common cause of chronic pain, which affects 54-80% of the population at some point in their life.  Epidural injections for the management of spinal pain is one of the most common interventions performed in many people although there is still some uncertainty regarding their effectiveness and safety. As they provide only transient relief and are associated with complications this intervention should only be used after all conservative methods have been tried. The revised policy provides clear guidelines on when to give epidural injections for back pain, for how long and how often and what to do when pain recurs after a course of injections.​

This is a new policy we have introduced this year. Hallux valgus is thought to be common with a prevalence of 28.4% in adults older than 40 years. Bunions are usually progressive. Referral for bunion surgery will be indicated only for pain and is not routinely performed for cosmetic purposes.

Alternative management includes conservative measures such as wearing low-heeled, wide shoes; oral analgesics (pain killers); the use of ice packs; bunion pads; orthoses placed inside the shoe; bunion splints.​​

Early surgery in carpal tunnel surgery is not as effective as in the later stages of the disease.

This policy update represents a change in the duration of conservative management (i.e. use of splints at night and steroid injections) of carpal tunnel surgery from the current 3 months to 6 months prior to referral for surgical opinion.

Clinicians should use the Shared Decision Making Tool (the conversation that happens between a patient and their health professional to reach a healthcare choice together) to explain the treatment to patients, together with its risks and benefits. ​

Recent evidence has demonstrated that hip replacement done prematurely before adequate conservative treatment has been given can lead to complications. In addition, hip replacement in people who are obese and/or chronic smokers leads to a high risk of complications. The updates to the policy provide clear guidelines on when to do surgery, the various conservative treatments that should be done in primary care and the use of Patient Decision Aids to arrive at a joint decision to have hip replacement.​

​Total knee replacement should only be recommended for moderate to severe persistent pain, which is not relieved by an extended course of non-surgical management, including weight management, or if the patient’s movement is limited resulting in a lesser quality of life, and there must be radiographic evidence of joint damage.​

​Requests for the surgical removal of second cataract(s) will only be supported when the patient has sufficient cataract to result in blurred or dim vision, or the cataract affects the patient’s lifestyle. Also the patient must have waited seven days to make a decision, wishes to undergo cataract surgery and understands the risks and benefits of this surgery. ​

Minor skin lesions include pigmented moles, comedones, corn/callous, lipoma, milia, molluscum contagiosum, sebaceous cysts (epidermoid or pilar cysts), seborrhoeic keratoses (basal cell papillomata), skin tags including anal tags, spider naevus (telangiectasia), warts, xanthelasma and neurofibromata.

A patient with a skin or subcutaneous lesion that has features suspicious of malignancy must be referred to an appropriate specialist for urgent assessment.​

Minor skin lesions will be treated through surgery if they are obstructing an orifice, or vision, limiting movement, causing disfigurement on the face, if there is recurrent bleeding, infection, inflammation, marked itching or severe pain which fails to respond to pharmacological treatment or if the lesion is located in an anatomic area subject to recurrent trauma. If there is any suspicion of malignancy, patients should be referred immediately to an appropriate service as described in NICE guidelines. The policy has been updated to clarify indications for surgery.​

A large proportion of the population will have gallstones detected on abdominal scans and not all have to be operated on. Last year data analysis revealed that there was a disproportionate number of surgeries done for asymptomatic gallstones. Hence the policy has been updated to clarify the few indications when surgery is needed for these patients.​

Circumcision surgery is not funded by the CCG. However, there is a number of exceptional clinical circumstances where surgery can be considered via the Individual Funding Request process, including the prevention of urinary tract infection in patients with an abnormal urinary tract, recurrent *paraphimosis, (e.g. zipper injury), tight foreskin causing pain on arousal/ interfering with sexual function or congenital abnormalities.

*paraphimosis is a urologic emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal position. It is important for clinicians to recognize this condition promptly, as it can result in gangrene and amputation of the glans penis.​

​Access to surgery has been brought into line with NICE guidance. Surgery will be recommended where there is a recurrent sore throat, where the majority of episodes have required antibiotic treatment, and where there has been a significant impact on the quality of life of the patient. Applications for funding are more likely to be approved where there are documents supporting evidence that the patient has attended general practice or other health care settings or sleep studies, growth charts, letters from GPs and letters from employers, school or playgroup in respect of time off. ​

Changes have only been made for adults with grommets. Evidence on their efficacy and use has evolved and there are very few specific indications to do them in adults. The CCG will only fund grommet insertion in adults (aged 18 and over) when one of the following criteria is met:

  • Insertion of grommets is part of a more extensive surgical procedure
  • There is Eustachian tube dysfunction (blockage) that prevents the commencement or completion of hyperbaric oxygen treatment or acute or chronic otitis media with risk of complications of facial palsy or intracranial infection such as meningitis
  • As a treatment for Ménière’s disease or in the case of conditions e.g. nasopharyngeal carcinoma, ethmoidal cancer, maxillectomy, olfactory neuroblastoma, sinunasal cancer, and complications relating to its treatment (including radiotherapy), if judged that the risks outweigh the benefit by the responsible clinician.

Varicose veins are very common in the general population and vary in severity from just cosmetic disfigurement to severe ulcers. Access has been brought into line with NICE guidance, so that only patients with the symptoms set out by NICE will be referred for surgery.

Surgery in the NHS will largely be funded for severe varicose veins – these are varicose veins that have bled or are bleeding from a varicosity that has eroded the skin. In this case a patient should be urgently referred. Or, if they have an ulcer and/or progressive skin changes indicative of varicose eczema that may benefit from surgery.

Moderate varicose veins with symptoms, including: itching, aching, mild swelling, and the minor skin changes of eczema haemosiderosis may be considered for surgery if there is objective evidence of rapid worsening of the condition.

Individual funding approval must be obtained prior to referral.

Given the financial challenge the CCG is facing and the huge waiting list for many patients with severe life threatening illness there is a need to rationalise on such procedures. Procedures of cosmetic nature will be funded if there is evidence of severe psychological disturbance that can’t be managed by non-surgical means or the condition is leading to severe physical limitation impacting on daily living. Changes to clarify clear indications for surgery have been made to procedures like rhinoplasty (surgery to reshape the nose), pinnaplasty / otoplasty (surgery on ears).​

  • A PoLCE is a procedure where the clinical effectiveness of that procedure is either absent or evidence shows weak efficacy and long term benefits reached
  • A PoLCE could be a procedure which is clinically effective but only under certain conditions, such as when a person meets certain criteria, otherwise more conservative alternatives should be tried first
  • A PoLCE is a treatment of a condition where not funding the treatment will not result in a significantly adverse effect on the patient’s physical or mental health

are evidence-based recommendations for health and care in England, from the National Institute for Health and Care Excellence.​