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OxfordshireClinical Commissioning Group

Oxfordshire CCG Commissioning Decisions – Clinical Commissioning Statements (formerly known as Lavender Statements)

July 2018

Oxfordshire Clinical Commissioning Group (OCCG) Clinical Ratification Group (CRG) makes decisions on behalf of the Governing Body regarding the commissioning of various treatments. It has approved the following new and updated Clinical Commissioning Statements. These will be put onto the OCCG website within a week from 10/7/2018 and provider organisations will have 4 weeks for implementation i.e. by 10/8/2018. This is in accordance with the contract.

Statements subject to prior approval will also be ‘live’ on Blueteq from that date and Blueteq must be used to comply with contractual terms and conditions.

Patients who have already been offered treatment under a previous statement may continue as planned. The date at which treatment was offered should be clear in the notes for audit purposes.

The OCCG website page may be found at; http://www.oxfordshireccg.nhs.uk/professional-resources/policies.htm

The table below contains the most recent decisions by the CRG.

Updated Statements – Content changed (attached)

Number Title Explanation of what has changedPlease note that the attached policy is for information – please use the version on the OCCG website http://www.oxfordshireccg.nhs.uk/professional-resources/policies.htm

Approval mechanism – if any

6i Aesthetic treatments for adults and children

Aesthetic treatments are not normally funded. However this policy also indicates the clinical circumstances in which those treatments usually used for aesthetic reasons may be funded.

From July 2018 it now clarifies the circumstances in which breast prostheses might be, inserted, removed and replaced;4. Prosthesis for breast – except reconstruction as part of the breast cancer care

pathway5. Removal of breast prosthesis is not permitted except as part of the breast cancer care pathway, ruptured/leaking implants, hardened/painful prosthesis, late onset seroma

A Blueteq prior approval form will be available for removal of breast prostheses

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http://www.oxfordshireccg.nhs.uk/professional-resources/policies.htm

or any suspicion of BIA-ALCL and known PIP-implants as per DoH guidelines.6. Revision of breast prosthesis, except as indicated by (4) above (patients having prosthesis removed for other medical reasons should be advised that replacement is not normally funded)

126c Cataract removal in adults – threshold for surgery

This policy is now in line with recommendations in NICE and commissioning statements of other Thames Valley CCGs.Full details are in the policy below but in brief it states that;

The cataract must be sufficient to account for the visual symptoms

and Either – Visual acuity of 6/12 or worse or the symptoms negatively affect the patient’s lifestyle – examples are given.In addition the patient must understand benefits and risks and want to undertake surgery.The same thresholds apply to both first and second eye

Prior approval via Blueteq will be available.

181c Smoking cessation before planned surgery

A previous Oxfordshire policy has been in place for a number of years. This policy has been reworded in line with the Thames Valley CCGs.

There is no change to the intention of the policy which is that GPs and secondary care clinicians must record the smoking status of the patient, confirm that a referral for stop smoking services has been made or the reason for an opt-out and that advice has been given.(Ask – Advise – Act)

Patients who choose to continue to smoke will not be denied surgery or have their surgery delayed unless the surgeon/anaesthetist considers the risk to the patient is too great.

Prior approval forms for elective surgery will be amended to include recording of smoking status and that advice has been given

269b Subacromial decompression for shoulder impingement

Thresholds for treatment remain unchanged. Policy wording has been amended to clarify that the policy refers to the treatment of shoulder impingement.

Prior approval in place

New Statements (attached)Number Title Brief explanation290 Female

SterilisationThis Thames Valley Policy states that due to associated levels of regret and the availability of more cost-effective methods of contraception female sterilisation is not normally funded

Individual Funding Request only

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Withdrawn StatementsNumber Title ExplanationNone this month

Linda Collins Clinical Effectiveness Manager OCCG

July 2018

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Aylesbury Vale Clinical Commissioning GroupBracknell and Ascot Clinical Commissioning Group

Chiltern Clinical Commissioning GroupNewbury and District Clinical Commissioning Group

North and West Reading Clinical Commissioning GroupOxfordshire Clinical Commissioning Group

South Reading Clinical Commissioning GroupSlough Clinical Commissioning Group

Windsor, Ascot and Maidenhead Clinical Commissioning GroupWokingham Clinical Commissioning Group

Thames Valley Priorities Committee Commissioning Policy Statement

Policy No 6i (TVPC16) Aesthetic treatments for adults and children

Recommendation made by the Priorities Committee: March 2015

Date of issue: May 2007; revised September 2008, reviewed February 2012, November 2015, updated September 2017, minor amendment May 20181 and July 2018²

The Thames Valley Priorities Committee has considered the evidence for the clinical and cost effectiveness of aesthetic treatments. The Committee found insufficient evidence of clinical and cost effectiveness to warrant the commissioning of aesthetic treatments and therefore these procedures are not normally funded. Adults and children will not normally be offered aesthetic treatments in either specialist, secondary or primary care.

Aesthetic or cosmetic interventions are intended to change aspects of a person's appearance. There has been a general policy of non-purchase of aesthetic treatments since 1996. However, procedures continue to be carried out without the prior approval of NHS commissioners. It has been re-confirmed by the Thames Valley Priorities Committee that no referrals should be made by GPs, or other clinicians, for any aesthetic procedure. Referring patients for treatments that can only be funded in exceptional circumstances may raise false expectations.

If clinicians consider that their patient’s case for an aesthetic intervention provides grounds for funding as an exception to policy, then an application for individual funding should be submitted to their NHS Clinical Commissioning Group

However, clinicians and patients making individual funding requests should be aware that:

aesthetic surgery procedures will normally only be considered in patients with a BMI in the range 18.5-27 (unless weight is not a relevant factor)

previous NHS-funded breast surgery does not guarantee further NHS surgery

1 Signpost inserted to Policy Statement 280 Entropion and ectropion² Clarifies that removal of breast implants is permitted for patients with specified symptoms

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aesthetic surgery for the removal of redundant skin as a result of NHS funded weight loss programmes or bariatric surgery will not normally be funded

Local CCG policies relating to smoking cessation and surgical procedures will apply.

A list of examples of aesthetic interventions that are not commissioned is provided below. It should be noted, however, that this list is illustrative and not exhaustive.

Examples of aesthetic procedures not normally funded

Breast surgery1. Breast lift (mastopexy) 2. Correction of inverted nipple 3. Removal of supernumerary nipples (polymastia) 4. Prosthesis for breast - except reconstruction as part of the breast cancer care

pathway 5. Removal of breast prosthesis is not permitted except as part of the breast cancer care pathway, ruptured/leaking implants, hardened/painful prosthesis, late onset seroma or any suspicion of BIA-ALCL and known PIP-implants as per DoH guidelines.6. Revision of breast prosthesis, except as indicated by (4) above (patients having prosthesis removed for other medical reasons should be advised that replacement is not normally funded)7. Breast augmentation8. Breast reduction with no concurrent breast pathology (see Guidance note 1)9. Revision of breast reduction or augmentation 10. Male breast tissue reduction (gynaecomastia) (see Guidance note 2)

Skin and hair 1. Destructive interventions to treat benign skin lesions (see Guidance note 3)2. Excision of redundant skin, subcutaneous tissue or fat, including abdominoplasty, apronectomy, buttock lift, thigh lift, upper arm reduction (brachioplasty); buttock augmentation and body contouring procedures, e.g., following weight loss interventions/surgery 3. Liposuction of subcutaneous tissue4. Surgery for divarication of the abdominal recti 5. Aesthetic operations on umbilicus 6. Tattoo removal 7. Dermabrasion 8. Cosmetic revision of scars (keloid and hypertrophic scars) 9. Hair transplantation / hair graft / intralace for hair loss10. Laser hair removal 11. Vaginal tightening and vaginoplasty* 12. Refashioning of the vaginal labia* *Please note: Clinicians must be assured that there is a clear clinical rationale for any potential intervention as all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons are defined as Female Genital Mutilation and as such are against the law. (The Female Genital Mutilation Act 2003).

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Clinicians must be alert to the possibility that some patients who seek revision surgery may do so as a result of previous interventions which are classed as unlawful under the Act.

Surgery to the face 1. Laser / Pulse Dye Laser Treatment of ‘Port Wine Stains’ and other skin lesions2. Surgery for prominent / bat ears (pinnaplasty / otoplasty) 3. Liposuction of neck and jowls (submental lipectomy) 4. Face lift (rhytidectomy) 5. Brow lift 6. Eyelid surgery (blepharoplasty), including ptosis of eyelid (see Guidance note 4)7. Nose reshaping (rhinoplasty/septorhinoplasty) 8. Non-urgent repair of lobe of external ear 9. Surgery to correct a bulbous/ruddy nose (rhinophyma) 10. Tooth whitening and dental veneers 11. Botox for anti-aging 12. Laser eye surgery for the avoidance of wearing glasses

For management of ectropion and entropion, see Policy Statement 280; Ectropion and entropion

For the treatment of hyperhidrosis (excessive sweating), see Policy Statement 70b; Hyperhidrosis.

For the treatment of varicose veins, see Policy Statement 1d; Varicose veins. For management of facial hirsutism, see Policy Statement 76b: The

management of facial hirsutism For dental implants, contact NHS England area team or NHS England website

for Primary Dental Services.

NOTES: Potentially exceptional circumstances may be considered by a patient’s CCG where there is

evidence of significant health status impairment (e.g. inability to perform activities of daily living) and there is evidence that the intervention sought would improve the individual’s health status.

This policy will be reviewed in the light of new evidence or new national guidance, e.g., from NICE.

Thames Valley clinical policies can be viewed at http://www.fundingrequests.cscsu.nhs.uk/ Oxfordshire CCG clinical polices can be viewed at http://www.oxfordshireccg.nhs.uk/policies-and-

procedures/

These Guidance notes are based on the experience of Thames Valley IFR Panels and local clinical opinion:

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http://www.oxfordshireccg.nhs.uk/policies-and-procedures/

http://www.oxfordshireccg.nhs.uk/policies-and-procedures/

http://www.fundingrequests.cscsu.nhs.uk/

1. Guidance for applicants for breast reduction surgery. Applications for funding as an exception to the policy will normally only be considered in patients in whom all of the following apply:

The individual patient’s breast development is considered to be complete Where the BMI is stable below 27kg/m2 for 9 months prior to referral Bra cup size of greater than GG Where medically documented evidence of a clinically significant history of

back, neck or shoulder pain, which has not resolved despite treatment(s), has been provided ;

Medically documented evidence of a clinically significant history of intertrigo or ulceration which has not responded to treatment;

Please note the above are not criteria for funding. However if these criteria are not met it is unlikely that a clinician could sustainably argue that an individual had an exceptional capacity to benefit from breast reduction.

2. Guidance for applicants for breast reduction surgery for gynaecomastia. Applications for funding as an exception to the policy will normally only be considered in patients if they meet all the following: Who have completed puberty; Whose BMI is ≤ 25kg/m2 (or the gynaecomastia is not caused by the weight

alone) No treatable cause is likely to reduce/reverse the gynaecomastia; In cases of idiopathic gynaecomastia in men under the age of 20, a period of

at least 2 years has been allowed for natural resolution.

Please note the above are not criteria for funding. However if these criteria are not met it is unlikely that a clinician could sustainably argue that an individual had an exceptional capacity to benefit from breast reduction for gynaecomastia.

3. Guidance for considering applications for removal of symptomatic skin lesions and lipomata.

Destructive interventions to treat benign asymptomatic skin lesions are not normally funded.

This includes warts (plantar warts); seborrhoeic keratoses (benign skin growths, basal cell papillomas, warts); spider naevi; thread veins; benign pigmented naevi (moles); dermatofibromas (skin growths); skin tags; ‘sebaceous’ cysts (pilar and epidermoid cysts); lipomata (fat deposits underneath the skin); xanthelasmas (cholesterol deposits underneath the skin); vitiligo i.e. loss of skin pigmentation. Removal of benign symptomatic skin lesions can be considered for patients where the lesion is associated with any one of the following:

repeated infection, inflammation or discharge bleeding in the course of normal everyday activity obstruction of an orifice to the extent that function is or is likely to become impaired pressure symptoms e.g. on an organ, nerve or tissue

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Removal of lipomata can be considered for patients where the lipomata is associated with any one of the following:

>5cm in diameter deep seated there is functional impairment the lump is rapidly growing or abnormally located (e.g. sub-fascial, sub-

muscular)

In case of clinical concern regarding malignant change usual referral guidance applies.

4. Guidance for considering applications for referral for eyelid surgery (blepharoplasty), including blepharoptosis (an abnormal low-lying upper eyelid margin) and dermatochalasis (skin redundancy of the upper lid).

Surgery can be considered for patients with the following symptoms: down-gaze ptosis impairing reading and other close-work activities

AND a chin-up backward head tilt due to visual axis obscuration

OR any one of the following: margin reflex distance 1 (MRD(1)) of 2mm or less eyelid skin fold to reflex distance of 2mm or less superior visual field loss of at least 12 degrees or 24% central visual interference due to upper eyelid position


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Policy No. 126c (TVPC 60) Cataract Removal in Adults – thresholds for surgery Recommendation made by the Priorities Committee: January 2018

Date Agreed OCCG July 2018

Date of issue: November 2008, amended June 2010, reviewed August 2016, July 2018

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When considering referring a patient for first or second eye cataract surgery the following thresholds must be met to ensure that surgery is a cost effective intervention:

1. The cataract must be sufficient to account for the visual symptoms (visual loss or disturbance) experienced by the patient. Alternative causes for the reported visual symptoms should be excluded prior to referring a patient for cataract surgery AND

2. Visual Acuity 6/12 or worse in either eye OR

3. The cataract and visual symptoms experienced by the patient should negatively affect the patient’s lifestyle. The following are examples for consideration for this threshold:

Significant glare or dazzle in daylight due to lens opacities Difficulty with night vision due to lens opacities particularly if driving A requirement for good vision for employment or caring purposes Difficulty reading e.g significant anisometropia or aniseikonia Management of other coexisting eye conditions, including DRSS (diabetic

retinopathy screening service) ungradable photograph Refractive error primarily due to cataract

4. The patient must understand the general benefits and risks of surgery AND

5. The patient must want to undertake the surgery when all the above is considered.

Cataract surgery should not normally be performed solely for the purpose of correcting longstanding pre-existing myopia or hypermetropia.

The same thresholds will apply for second eye surgery.




Thames Valley clinical policies can be viewed at http://www.fundingrequests.cscsu.nhs.uk/ Oxfordshire CCG clinical polices can be viewed at http://www.oxfordshireccg.nhs.uk/professional-

resources/policies

OPCS-4 codes: C71-C74 (lens extraction) and C75.1 (lens replacement)

Buckinghamshire Clinical Commissioning GroupEast Berkshire Clinical Commissioning Group

Oxfordshire Clinical Commissioning Group

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West Berkshire Clinical Commissioning Group


Policy No. 181c (TVPC78) Smoking cessation before planned surgery Recommendation made by the Priorities Committee: May 2018

Date agreed by OCCG July 2018

Date of issue: October 2010, August 2016 (No change to policy) January 2017, July 2018

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Patients who smoke and who are identified as needing routine planned surgery must be advised to stop smoking and should be referred to a smoking cessation service prior to their operation.

GPs and secondary care clinicians must record the smoking status of the patient, confirm that a referral for stop smoking service has been made or the reason for an opt-out and advice given, as applicable.

There are significant positive effects of stopping smoking in the 8 weeks running up to surgery. Stopping smoking any time before surgery has no detrimental effects for patients.

This view is supported by the Joint briefing by Action on Smoking and Health (ASH), the Royal College of Anaesthetists, the Royal College of Surgeons of Edinburgh and the Faculty of Public Health (April 2016) and NICE Guidance NG92 (2018) Stop smoking interventions and services.

NICE notes that evidence has showed that smoking delays recovery after surgery, therefore people should stop smoking before having elective surgery. Because this is so important, the NICE appraisal committee recommended that people planning surgery are referred for stop smoking support as an opt-out approach, rather than being offered a referral (an opt-in approach).

Patients who continue to smoke despite pre-operative advice and support to stop smoking will not be denied surgery or have their surgery delayed, unless their surgeon/anaesthetist considers the risk to the patient is too great.

The role of health professionals

Health professionals have a key role to play in encouraging smokers to quit. Surveys have found that prompts from health professionals are the second most common reason for an attempt to quit. To make surgical care more effective and efficient, an integrated approach to patient care which includes joined up working between and across primary and secondary care, should be taken. This should take “fitness for surgery” into account and encourage smoking cessation prior to

Contacts:Smoke Free Berkshire https://www.smokefreelifeberkshire.com/ Stop Smoking Bucks Health https://www.livewellstaywellbucks.co.uk/

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The role of health professionals

Health professionals have a key role to play in encouraging smokers to quit. Surveys have found that prompts from health professionals are the second most common reason for an attempt to quit. To make surgical care more effective and efficient, an integrated approach to patient care which includes joined up working between and across primary and secondary care, should be taken. This should take “fitness for surgery” into account and encourage smoking cessation prior to

https://www.livewellstaywellbucks.co.uk/

https://www.smokefreelifeberkshire.com/

https://www.rcoa.ac.uk/sites/default/files/Joint-briefing-Smoking-Surgery.pdf

Smoke Free Oxfordshire https://www.smokefreelifeoxfordshire.co.uk/ NHS Choices https://www.nhs.uk/live-well/quit-smoking/take-steps-now-to-stop-smoking/




Thames Valley clinical policies can be viewed at http://www.fundingrequests.cscsu.nhs.uk/ Oxfordshire CCG clinical polices can be viewed at

http://www.oxfordshireccg.nhs.uk/professional-resources/policies

Berkshire East Clinical Commissioning GroupBuckinghamshire Clinical Commissioning Group

Oxfordshire Clinical Commissioning GroupWest Berkshire Clinical Commissioning Group


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https://www.nhs.uk/live-well/quit-smoking/take-steps-now-to-stop-smoking/

https://www.nhs.uk/live-well/quit-smoking/take-steps-now-to-stop-smoking/

https://www.smokefreelifeoxfordshire.co.uk/

Policy No. 269b (TVPC 50) Subacromial decompression for shoulder impingement

Recommendation made by the Priorities Committee: September 2016 (updated March 2018)2

Date agreed by OCCG July 2018

Date of issue: April 2018, minor update July 2018

The Thames Valley Priorities Committee has considered the evidence for clinical and cost effectiveness of subacromial decompression for shoulder pain due to shoulder impingement and recommends primary care referral can be considered for surgical opinion for patients who meet all of the following criteria:

Red flag symptoms:3




2 Minor editing for clarity no change to threshold. 3 https://www.boa.ac.uk/wp-content/uploads/2014/08/Subacromial-Shoulder-Commissioning-Guide_final.pdf

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Patient has had symptoms for at least 3 months from the start of treatment Symptoms are intrusive and debilitating (for example waking several times a night,

pain when putting on a coat) Patient has been compliant with conservative intervention (education, rest,

NSAIDs, simple analgesia, appropriate physiotherapy) for at least 6 weeks Patient has initially responded positively to a steroid injection but symptoms have

returned despite compliance with conservative management Referral is at least 8 weeks following steroid injection Patient confirms they wish to have surgery.

Emergency referral - same day: Acutely painful red warm joint– e.g. suspected infected joint. Trauma leading to loss of rotation and abnormal shape - unreduced

shoulder dislocation.

Urgent referral (<2/52) to secondary care: Shoulder mass or swelling - suspected malignancy Sudden loss of ability to actively raise the arm (with or without trauma) -

acute cuff tear. New symptoms of inflammation in several joints - systemic inflammatory

joint disease (rheumatology referral).

Thames Valley clinical policies can be viewed at http://www.fundingrequests.cscsu.nhs.uk/ Oxfordshire CCG clinical polices can be viewed at


OPCS Procedure Codes:O29.1 Subacromial decompression

Secondary OPCS codes:Z94.1 Bilateral operationZ94.2 Right sided operationZ94.3 Left sided operationZ94.4 Unilateral operationY71.3 Revisional operations NOCW572 Primary excision arthroplasty of joint NECT79.1 Plastic repair of rotator cuff of shoulder NECW84.4 Endoscopic decompression of jointY767 Arthroscopic approach to joint

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Policy No. 290 (TVPC68) Female Sterilisation Recommendation made by the Priorities Committee: July 2017

Agreed by OCCG July 2018

Date of issue: July 2018

NOTES: Potentially exceptional circumstances may be considered by a patient’s CCG where there is evidence of

significant health status impairment (e.g. inability to perform activities of daily living) and there is evidencethat the intervention sought would improve the individual’s health status.

This policy will be reviewed in the light of new evidence or new national guidance, e.g., from NICE. Thames Valley clinical policies can be viewed at http://www.fundingrequests.cscsu.nhs.uk/ Oxfordshire CCG clinical polices can be viewed at

Thames Valley Priorities Committee has reviewed the provision of female sterilisation services across Thames Valley CCGs.

Due to associated levels of regret and the availability of more cost effective methods of contraception, female sterilisation is not normally funded.

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