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					                                                                        Effective from 1st August 2006
                                                        Low Priority Treatment/ Procedures Policy Guidance Notes


   Summary of low priority treatments/procedures where guidelines apply in order to safeguard the use of public monies .
   Referrals for these treatments should no longer be made to secondary care, unless there is evidence to suggest that an exceptional reason may
    apply, as described in this guidance.
   Where there is no written supporting evidence in the GP referral letter, the referral will be returned to the GP by the Consultant. Photographs can
    be submitted as additional evidence.
   If the Consultant assesses the patient and considers both that the patient meets the exceptional criteria and that surgery is indicated, then the
    patient can be placed on the treatment waiting list .
   All cases will be considered on an individual basis. If the GP/Consultant considers the patient to have exceptional clinical needs but are excluded
    under the policy, they should make an application for funding directly to the PCT Clinical Panel. If this application is rejected, a PCT appeals
    system is also in place.
   Please note that referrals within the NHS for the revision of treatments originally performed outside the NHS will not usually be permitted.
    Preferably such referrals should be re-directed to the practitioner who carried out the original treatment.
   These guidelines have been formulated following consultation with Consultants in the speciality areas and are adapted from the NHS
    Modernisation Agency’s document: ‘Action On Plastic Surgery’-Information for Commissioners of Plastic Surgery Services. Referrals and
    Guidelines in Plastic Surgery: http://www.wise.nhs.uk/sites/clinicalimprovcollab/surgery-plastic/Surgery%20Plastic%20Documents/1/Inclusion.pdf


(A) General Exceptional Circumstances (can apply to ALL low priority treatments/procedures):

The patient may be considered exceptional on either physical or psychological grounds as follows:

    1. Physical grounds: where the treatment is likely to achieve significant relief of pain or improvement in the disease process.

    2. Psychological grounds: the condition requiring treatment is causing the patient such significant mental distress that it significantly limits his/her family
       life and/or his/her ability to function socio-culturally or at work, and that there is good reason to believe that treatment will substantially relieve his/her
       mental distress and overall level of functioning, and that there is a significant likelihood that the individual will gain much higher than average benefit from
       the treatment.

         Patients are assessed by the Psychological Liaison Service under Dr Friedman after the patient has been seen and assessed by the consultant who is
         considering carrying out the relevant treatment. If the psychological assessment concludes that there are exceptional grounds for treatment, then the
         patient can be placed on the treatment waiting list.

         If it is felt that a patient is suffering from a significant underlying mental illness, it is imperative that the illness is fully treated before any treatment within the
         Exceptional Treatment Policy is considered.

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                                                                    Effective from 1st August 2006




(B)    Examples of Specific Exceptional Circumstances:

         Speciality                   Treatments not routinely funded     Treatments that can be directly referred   Guidance on exceptional reasons where
                                                                                                                     GP may make a referral for a consultant
                                                                                                                                    opinion

SKIN AND SUBCUTANEOUS CONDITIONS
Dermatology, General Benign skin or subcutaneous lesions with All skin or subcutaneous lesions                       Benign skin or subcutaneous lesions that
Surgery,             no risk of malignancy or infection. suspected of being malignant should be                      are symptomatic i.e. they are functionally
Plastic Surgery      Treatment of the following is considered referred urgently.                                     disabling,    becoming       traumatised   or
                     to be cosmetic and should not be                                                                recurrently infected or if there is diagnostic
                     referred:                                                                                       doubt.
                                                                Genital warts should be referred to
                      Uncomplicated viral warts including         Department of Genitourinary Medicine
                         plantar warts (see dermatology  Warts on the eyelids should be                                Warts should normally be treated in
                         therapeutic guidelines)                   referred directly to Ophthalmology.                   Primary Care (within the GP‟s core
                      Seborrhoeic warts                        Anal skin tags should be referred                       contract) if it is deemed that treatment is
                      Molluscum contagiosum                       directly to General Surgery.                          needed (warts usually being self-
                      Acquired Spider telangiectasia and       Sebaceous cysts:                                        limiting).
                         thread-veins                                     o on the face
                      Skin tags and papillomas                           o over 2 cm diameter on the
                      Sebaceous cysts(see 2 column)
                                                 nd
                                                                               body or 1cm prominence
                      Lipomas                                                 on the scalp
                      Port      wine    stains     and  other            o recurrently infected, or
                         haemagiomas (see 2nd column)                          subject to trauma
                      Benign moles                             Port wine stains:
                      Male pattern alopecia (physiological               o in adults on necessarily
                         balding in men)                                       exposed skin e.g face
                      Skin ageing with no evidence of solar              o other                      visible
                         keratosis, or any malignant or pre-                   haemangiomata anywhere
                         malignant lesion                                      on children (under the age
                                                                               of 19 at time of referral)
                                                                Xanthelasmata should have lipid
                                                                   profile checked before referral.
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                                                                      Effective from 1st August 2006
                                                                                  Topical treatment or cryotherapy may
                                                                                  be appropriate.


Plastic Surgery                   Tattoo removal.                                                                       Available where the tattoo is the result of
                                                                                                                        trauma, inflicted against the patient‟s will
                                                                                                                        (“rape tattoo”) or on an adult who was a child
                                                                                                                        under the age of consent (and not Gillick
                                                                                                                        competent) at the time of the tattooing.
                                                                                                                        Tattoos inflicted under duress during
                                                                                                                        adolescence or disturbed periods and where
                                                                                                                        the tattoo causes marked limitation of
                                                                                                                        psycho-social function may be considered.
Dermatology                       Hypo-pigmentation                          The recommended treatment is cosmetic Correction of hypo-pigmentation following
                                                                             camouflage, available at UHL               laser surgery is not available in the NHS,
                                                                                                                        except if the laser treatment was performed
                                                                                                                        under the NHS.
Dermatology/Plastic               Dermabrasion and/or laser resurfacing                                                 Treatment may be available in exceptional
Surgery                                                                                                                 circumstances following discoid lupus or
                                                                                                                        other facial skin diseases causing scarring,
                                                                                                                        once the active disease is controlled (such as
                                                                                                                        post-acne scarring), or following trauma (such
                                                                                                                        as dirt-engrained scars).
Vascular                          Axillary hyperhidrosis                     Sympathectomy may be considered. If this
Surgery/Plastic Surgery                                                      treatment fails wide excision and skin
                                                                             grafting or treatment with botulinum toxin
                                                                             may be indicated.
Plastic Surgery                   Botulinum Toxin                            Available for treatment of pathological Not available for the treatment of facial aging
                                                                             conditions by appropriate specialists-e.g. or excessive wrinkles.
                                                                             Frey‟s      syndrome,      blepharospasm,
                                                                             cerebral palsy and hyperhidrosis
Plastic Surgery                   Plastic excision of skin for cosmetic                                                 See below under face, brow lifts.
                                  indicators (facelifts, buttock lifts).
Plastic Surgery                   Photodestruction electrolysis of lesion of                                            Not available on the NHS.
                                  skin.




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                                                                     Effective from 1st August 2006

BREAST PROCEDURES
Plastic Surgery   Breast reduction                                                                    Available where all the following criteria are
                                                                                                      met:
                                                                                                       Patient is suffering neck ache,/backache
                                                                                                           and/or debilitating recurrent intertrigo
                                                                                                       The wearing of a professionally measured
                                                                                                           and fitted bra has not relieved the
                                                                                                           symptoms
                                                                                                       BMI is less than 30.
                                                                                                      The referral letter must include information on
                                                                                                      bra size, BMI, physical symptoms. Surgery
                                                                                                      will be restricted to patients in whom at least
                                                                                                      500g of breast tissue will be excised, unless
                                                                                                      the patient fulfils the General Exceptional
                                                                                                      Circumstances on page 1. Patients with
                                                                                                      breasts less than E cup will not normally be
                                                                                                      considered.
Plastic Surgery                   Breast reduction (male gynaecomastia).                              May be available for post-pubertal males with
                                                                                                      normal BMI (between 18 and 25) where there
                                                                                                      is excessive breast tissue.
                                                                                                      Patients should be screened by an
                                                                                                      Endocrinologist prior to referral to a Plastic
                                                                                                      Surgeon.
Plastic Surgery                   Breast augmentation.                                                This is available only in exceptional
                                                                                                      circumstances. It is not available to patients
                                                                                                      with normal but small breasts, or for breast
                                                                                                      tissue involution (including postpartum
                                                                                                      changes). Women with A cup or larger
                                                                                                      breasts will not normally be considered.
                                                                                                      Exceptional cases are those with virtual
                                                                                                      absence of breast tissue e.g.
                                                                                                       after mastectomy or other breast surgery
                                                                                                       trauma to the breast during or after
                                                                                                           development
                                                                                                       congenital amastia (total failure of breast
                                                                                                           development)
                                                                                                       endocrine abnormalities.
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                                                                        Effective from 1st August 2006
                                                                                                         Where patients undergoing gender re-
                                                                                                         assignment       treatment    request      breast
                                                                                                         augmentation, the same guidelines will apply
                                                                                                         as for biological females. See below for
                                                                                                         advice on breast implant replacement.
Plastic Surgery                   Breast asymmetry                                                       Breast augmentation may be offered to
                                                                                                         patients with unilateral absence of breast
                                                                                                         tissue after mastectomy etc (see above for
                                                                                                         causes of bilateral absence of breast tissue)
                                                                                                         or in women with a significant degree of
                                                                                                         asymmetry of breast shape and/or volume.
                                                                                                         Surgery for the contralateral breast will not
                                                                                                         normally be available unless this is an
                                                                                                         integral part of the treatment for the
                                                                                                         asymmetry.
Plastic Surgery                   Breast Mastopexy (breast uplift).                                      Not available for cosmetic purposes such as
                                                                                                         post-lactation       or   age-related       ptosis
                                                                                                         (droopiness).
                                                                                                         Available for patients who meet the agreed
                                                                                                         criteria for breast reduction or breast
                                                                                                         asymmetry (see above) or if the patient has a
                                                                                                         medical condition e.g. intertrigo and where
                                                                                                         there is a disabling effect upon daily living.
Plastic Surgery                   Removal of silicone breast implants                                    Implants will be removed if they are causing
                                                                                                         significant local damage to the breast.
                                                                                                         Replacement will be supported when:
                                                                                                          the original implant was put in for non-
                                                                                                              cosmetic reasons.
                                                                                                          the original operation was an NHS
                                                                                                              procedure.
                                                                                                          the risk to the patient‟s health from not
                                                                                                              replacing     the implant     substantially
                                                                                                              outweighs the risk to the patient from
                                                                                                              rupture and other complications from
                                                                                                              putting in a new implant i.e. based on
                                                                                                              clinical need.
                                                                                                          patient meets criteria for augmentation at
                                                                                                              time of revision (see above)
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                                                                         Effective from 1st August 2006
Plastic Surgery/Breast Nipple inversion                                         Underlying malignancy must always be   Surgical correction is only available for
Surgery                                                                         excluded*                              functional reasons in post-pubertal women if
                                                                                                                       the inversion has not been corrected by
                                                                                                                       correct use of a non-invasive suction device.
                                                                                                                       Surgical correction of nipple inversion results
                                                                                                                       in ductal disruption preventing lactation.
                                                                                                                       „Benign‟ nipple inversion can improve during
                                                                                                                       pregnancy.


FACIAL PROCEDURES
Plastic Surgery / ENT             Prominent ears in adults (19 years and                                               Patient must be under the age of 19 at the
                                  over)                                                                                time of referral and should be seen by a
                                                                                                                       plastic surgeon and, if there is any concern,
                                                                                                                       assessed by a psychologist.
ENT/Plastic Surgery.              Rhinoplasty                                                                          Only available for post-traumatic deformity
                                                                                                                       cases or as part of the correction of complex
                                                                                                                       congenital conditions e.g. cleft lip and palate.
                                                                                                                       Patients with associated airway problems
                                                                                                                       should be first referred to an ENT Consultant
                                                                                                                       for assessment.
ENT/Plastic Surgery               Rhinophyma                                  The first line treatment is medical      Severe cases or those that do not respond to
                                                                                                                       medical treatment may be considered for
                                                                                                                       surgery or laser treatment
ENT/Plastic Surgery               Split earlobes                                                                       Available for the repair of totally split earlobes
                                                                                                                       as a result of direct trauma, but not partially
                                                                                                                       split lobes or elongated holes in lobes
Plastic Surgery                   Hair bearing graft and hair implant.                                                 Correction of hair loss (alopecia) is available
                                                                                                                       when it is the result of previous trauma
                                                                                                                       including burns.
                                                                                                                       Hair transplantation will not be available
                                                                                                                       regardless of gender except in exceptional
                                                                                                                       circumstances such as reconstruction of the
                                                                                                                       eyebrow following cancer or trauma.
Dermatology                       Hair removal (depilation)                                                            May be available for patients who:
                                                                                                                        Have undergone surgery resulting in
                                                                                                                            abnormally located hair-bearing skin or
                                                                                                                        Have an underlying endocrine cause e.g.
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                                                                  Effective from 1st August 2006
                                                                                                       polycystic ovary syndrome
                                                                                                   and also:
                                                                                                    Have        a     significant    psychological
                                                                                                       impairment as set out in (A) above
Plastic Surgery                   Face or brow lift                                                Not available to treat the natural processes of
                                                                                                   aging. May be available for patients with:
                                                                                                        congenital facial abnormalities
                                                                                                        facial palsy (congenital or acquired
                                                                                                           paralysis) or
                                                                                                        as part of the treatment of specific
                                                                                                           conditions affecting the facial skin e.g.
                                                                                                           cutis      laxa,        pseudoxanthoma
                                                                                                           elasticum, neurofibromatosis
                                                                                                        consequences of trauma
                                                                                                        deformity following surgery;
Plastic               Upper lid blepharoplasty                                                     Available to correct functional impairment as
Surgery/Ophthalmology                                                                              demonstrated by impairment of visual fields in
                                                                                                   the relaxed, non-compensated state, clinical
                                                                                                   observation of poor eyelid function,
                                                                                                   discomfort e.g. headache worsening towards
                                                                                                   the end of the day and/or evidence of chronic
                                                                                                   compensation through elevation of the brow.
                                                                                                   Visual field assessment may be required.
Plastic               Lower lid blepharoplasty                                                     Available to correct ectropium or entropium or
Surgery/Ophthalmology                                                                              the removal of lesions of the eyelid skin or lid
                                                                                                   margins

BODY CONTOURING PROCEDURES
Plastic Surgery    Abdominoplasty (not following significant                                       May be available where the patient‟s BMI is
                   weight loss)                                                                    stable between 18 and 27 and following
                                                                                                   criteria are met:
                                                                                                         recurrent disabling intertrigo beneath
                                                                                                            the skin fold or
                                                                                                         severe scarring following trauma or
                                                                                                            previous      surgery   leading       to
                                                                                                            psychological distress or risk of
                                                                                                            infection, or
                                                                                                         severe difficulties with daily living i.e.
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                                                                    Effective from 1st August 2006
                                                                                                              ambulatory restrictions
                                                                                                      Abdominoplasty may be required as part of
                                                                                                     abdominal hernia correction or other
                                                                                                     abdominal wall surgery and for problems
                                                                                                     associated with poorly fitting stoma bags.
Plastic Surgery                   Abdominoplasty and/ or body contouring                             May be available where the patient‟s BMI is
                                  following significant weight loss.                                 stable between 18 and 27 and the following
                                                                                                     criteria are met:
                                                                                                           the weight loss has been maintained
                                                                                                              for at least two years
                                                                                                           recurrent disabling intertrigo beneath
                                                                                                              the skin fold
                                                                                                           severe difficulties with daily living i.e.
                                                                                                              ambulatory restrictions.

                                                                                                     *Patients with BMI above 27 who have had
                                                                                                     gastropexy or other surgical treatment for
                                                                                                     morbid obesity, have achieved significant
                                                                                                     weight loss and have excessive abdominal
                                                                                                     skin folds may be considered for
                                                                                                     abdominoplasty (i.e.tertiary referral)

                                                                                                     Patients may be eligible for contouring at
                                                                                                     diabetes       injections       sites (upon
                                                                                                     recommendation of the diabetologist), for
                                                                                                     lymphoedema, for thinning of skin flaps or
                                                                                                     post-gastric partitioning, where there is a
                                                                                                     disabling effect upon daily living.

Plastic Surgery                   Liposuction    and    other    cosmetic                            Not available on cosmetic grounds in order to
                                  operations on subcutaneous tissue.                                 simply correct the distribution of fat.
                                                                                                     Liposuction may be useful :
                                                                                                      contouring areas of localised fat atrophy
                                                                                                         or pathological atrophy (multiple lipoma
                                                                                                         stasis, lipodystrophies)
                                                                                                      as an adjunct to other surgical
                                                                                                         procedures.

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                                                                                  Effective from 1st August 2006

VASCULAR PROCEDURES
Vascular surgery   Varicose Veins not demonstrating                                      Two or more separate episodes of         Surgery is only appropriate for patients with
                  significant trophic/skin changes e.g                                   superficial thrombophlebitis should be   significant skin changes that indicate venous
                  venous eczema, oedema or ulceration.                                   referred for assessment by a vascular    hypertension and are therefore at risk of
                                                                                         surgeon.                                 developing venous ulcers. Significant skin
                                                                                                                                  changes include venous eczema, oedema or
                                                                                                                                  ulceration.

                                                                                                                                  Not available for pain or discomfort (throbbing
                                                                                                                                  etc). Even in the presence of varicose veins,
                                                                                                                                  most lower limb symptoms probably have a
                                                                                                                                  non-venous cause. There is a poor
                                                                                                                                  correlation between leg pain and the
                                                                                                                                  size/extent of varicose veins.

REVERSAL OF STERILSATION
Gynaecology, General Reversal of female                           sterilisation     or                                            Not available on the NHS.
Surgery, Urology     reversal of vasectomy.




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                                                                            Effective from 1st August 2006

      The following guidelines also need to be applied in order to ensure effective use of public money/ management of commissioning resources

                        Children with suspected autism            Referrals to independent sector or out of area services will only be considered for
                                                                  funding by the PCTs Clinical Panel where the child‟s care has been assessed by
                                                                  both CAMHS and paediatric services (either UHL or specialist community child
                                                                  health services).

                        High cost therapies                       Please note that there is a separate process for approval of funding for NICE and
                                                                  high cost therapies, agreed between PCTs and UHL. There is an internal UHL
                                                                  process and a Leicestershire & Northamptonshire NICE/ High cost therapies group
                                                                  (GPs can raise issues via their PCT Commissioning link)




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                                     Effective from 1st August 2006
A GP may refer a patient to the PCT Clinical Panel if:-


    1.       A referral to secondary care has been rejected on the grounds that the patient does not meet
             the exceptional criteria in the policy.
    2.       The patient has specific individual clinical needs that are not covered by the exceptional criteria
             in the policy.

                                  GP refers case to the PCT panel
                                  describing the individual clinical
                                  circumstances of patient




   Case approved                                                     Case not approved




   GP sends referral letter to                                    PCT informs GP and patient
   secondary care provider
   stating patient approved
   by PCT
                                          GP and/or patient appeal                  PCT decision accepted
                                          decision




                                          PCT convenes Appeals Panel
                                          to review decision




             Panel decision overturned                                 Panel decision upheld




Please refer County cases to:                                           Please refer City cases to:
Shelagh McKiernan                                                       Benjamin Adams (LCW) / Bharati Patel (EL)
Commissioning & Strategy Development Manager                            Strategy and Commissioning
3rd Floor                                                               4th Floor
PERA Innovation Park Nottingham Road                                    St. John‟s House
Melton Mowbray                                                          30 East Street
Leicestershire                                                          Leicester
LE13 0RH                                                                LE14 2LW

Telephone: 01664 855 572                                                Telephone: 0116 295 1516/4113

Email: shelagh.mckiernan@lcrpct.nhs.uk                                  Email: mailto:Benjamin.adams@lcwpct.nhs.uk
                                                                               mailto:Bharatidevi.patel@elpct.nhs.uk


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                                                                        Effective from 1st August 2006
                                                              Management of referrals by Secondary Care


                                                      Referral letter from GP for condition/treatment in the policy


Referral letter contains necessary information (as
set out in policy guidance) that case is                        Referral letter does not contain sufficient                Referral letter indicates case is
exceptional                                                     information to judge if exceptional case                   not exceptional



Outpatient clinic appointment arranged and
patient attends



Consultant considers case                  Consultant considers case
appropriate for treatment                  appropriate for treatment but requires            Consultant considers case
and meets exceptional                      psychological assessment to meet                  inappropriate for treatment           RETURN TO GP
criteria                                   exceptional criteria                              and/or does not meet
                                                                                             exceptional criteria



PATIENT LISTED FOR
TREATMENT                                        Liaison psychiatry
                                                 appointment arranged
                                                 and patient attends




              Psychological assessment                             Psychological assessment does not
              meets exceptional criteria                           meet exceptional criteria




        TD/cdh/Commissioning/ExceptionalTreatment/Flowchart

				
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