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					Meeting:        Brighton & Hove City Teaching PCT Board Meeting


Item no:        045/08


Date:           11th March 2008

Author:         Terry Baker, Director of Assurance and Development

Subject:        Process for the Funding of Individual Continuing Care or
                Acute Exceptions Cases



1.      Purpose The purpose of this paper is to describe the process which will
        be employed by Brighton and Hove City Teaching Primary Care Trust for
        reaching decisions regarding the commissioning and funding of care for
        individual patients. It also includes the draft terms of reference for the
        committees involved in the process and lists the policies which are in use
        currently in reaching decisions.

2.      Summary The PCT will establish two funding panels as follows:

             The Continuing Care Panel
             The Exceptions Panel

        Each panel will consider requests as outlined below in order to provide a
        transparent and equitable decision making process. It is proposed that the
        PCT will also establish an Appeals Panel to consider appeals against
        funding decisions made.

        From 1st October 2007 the “National Framework for NHS Continuing
        Health care and NHS funded care” will apply in respect of continuing care
        cases under consideration. This framework requires the PCT to fund any
        case which meets the criteria.

        The Exceptions Panel will consider cases where individuals may have
        exceptional circumstances and are seeking funding where the treatment
        or procedure has not been prioritised by the PCT.
3.   Recommendations The Board is asked to approve the process for
     determining the funding of care for individual patients and the Terms of
     Reference for the panels involved. The Board is also asked to ratify the
     policies listed in Appendix 3 and to note those awaiting recommendation
     from the Professional Executive Committee listed in Appendix 4.

4.   Background information The PCT is responsible for providing for the
     health needs of its residents and for complying with its statutory duty to
     break even. In determining which procedures and treatments it should
     provide the PCT has discretion as to the allocation of its resources and
     does not have an obligation to fund all requested treatments or
     procedures, especially where more cost effective alternatives are
     available. Funding decisions regarding individual cases are made by the
     PCT.

     The PCT uses a range of clinical policies to inform decisions regarding the
     treatment of individuals. These policies are aimed at ensuring that the
     procedures which the PCT commissions are:

        Appropriate to receive NHS funding
        The most appropriate clinical response to the patient’s problem
        Of demonstrable clinical benefit to patients

     The list of policies which are currently approved by the PCT are listed in
     Appendix 3. Appendix 4 contains details of policies which will be
     discussed by the PEC in March 2008 for approval by the Board in May
     2008.

     All policies, once approved, are used by the funding panels to reach
     decisions about whether to fund an individual treatment or package of
     care. An Appeals Panel will consider any case referred to it where the
     patient or their representative (with explicit consent to act on the patient’s
     behalf) wishes to challenge the original decision.

     The PCT will need to be able to justify its decisions to the wider
     community for which there are four key questions:

           Was due process followed in relation to the case being considered?
           What were the grounds for making the decision?
           Has there been consideration of the exceptional individual
            circumstances and has the exceptions panel considered the case
            for exceptional circumstances appropriately?
           Has new evidence or additional information been provided as part
            of the appeal that merits further consideration by the Exceptions
            Panel?
5.    Link to corporate objectives
      a.    Health improvement and health outcomes. Decisions regarding
            the funding of individual treatments and care will take account of
            equity and the intended health outcomes of patients.

      b.    Commissioning excellent health care services. The process
            detailed in this paper is concerned with ensuring that service
            provided to individual patients are based on the best available
            evidence and take due consideration of the individual’s choice and
            circumstances.

      c.    Public confidence. Ensuring that decisions are taken in a publicly
            transparent and fair manner will help to deliver confidence in the
            PCT’s decision making processes.

      d.    Finance, value for money and governance. In reaching
            decisions regarding the funding of individual treatments or
            procedures the PCT will take into account value for money to the
            NHS and the need to achieve financial balance. £400,000 has been
            identified as the potential saving from the commissioning of
            clinically effective procedures.

      e.    Leadership and relationships. There is no direct link to leadership
            and relationships in this paper.

6.    Impact on health. The clinical policies and their application will impact on
      the health of the individuals under consideration for funding. The improved
      targeting of PCT resources to clinically effective procedures will maximise
      the potential health improvement for the population.

7.    Personnel issues. There are no directly applicable personnel issues in
      respect of this paper.

8.    Equalities issues. Individual patients will not be discriminated against in
      the application of this process and the use of clinical policies.

9.    Financial implications including value for money. Value for money will
      be considered in determining the funding of individual treatments.

10.   Consultation. Consultation is required with clinicians and the public in
      setting clinical policies and exception criteria.
11.   Appendices

      Appendix 1: The process for making decisions on the funding of
                  individual treatments
      Appendix 2: Appeals Panel, Continuing Care Panel and Exceptions
                  Panel Terms of Reference
      Appendix 3: List of policies approved by the PCT
      Appendix 4: List of policies to be discussed by the PEC in March 2008
                                                                       Appendix 1

                      The Process for making decisions
                    on the funding of individual treatments

Introduction
The PCT is required to serve the needs of its population and is also required to
comply with its statutory requirement to break even. It is well established by the
courts that the PCT does not have an absolute obligation to provide every
treatment requested by patients but it is entitled to develop policies which
prioritise treatments taking account of available resources and competing
demands. There is therefore an element of judgement by the PCT.

However, in reaching judgements and decisions the PCT is required to have
relevant policies in place and a process which enables the consideration of each
individual request on its own merit against the policies, even if funding is only
given in exceptional cases. Requests may be lawfully denied on the grounds of
cost, lack of priority, unproven clinical effectiveness or a combination of these.

The process which is put in place should clarify:

          Who takes the decision
          What criteria are used in reaching a decision
          What procedure is adopted in each case

Authority for taking decisions

Setting priorities
Each year the PCT takes investment and disinvestment decisions for the coming
financial year. For 2008/09 onwards this is set out in the Annual Operating Plan.
This document takes account of the PCT’s commissioning plans and strategies
and the needs of the population as a whole. The PCT would not expect to make
substantial decisions outside of this process and, in particular, to commit new
resources in year to the funding of new drugs, procedures etc as this would
inevitably mean destabilising previously identified priorities.

To support the planning process the PCT uses advice from the local Priorities
Group and the South East Coast Health Policy Support Unit.

Decision Making Panels
The PCT has established the Continuing Care Panel and the Exceptions Panel to
discuss cases, apply the criteria and reach a decision on whether to agree to
fund treatment for individuals. The terms of reference of these panels are
included at Appendix 2. This states the membership, remit and authority of the
panel. It is not the function of the panels to set commissioning policy for the PCT.
Considerations by the exceptions panel start from the point of whether the
treatment has been prioritised through the Annual Operating Plan. Exceptional
circumstances will then be considered. The continuing care panel uses nationally
set criteria and policies.

Appeals Panel
The PCT has several options open to it following the decisions of the above
panels.

           To not have an appeal process at all. There is no legal requirement to
            constitute an appeals panel and the PCT could rely on the decisions of
            the continuing care and exceptions panel as final except for individuals
            who wish to challenge through judicial review.
           Establish the appeals panel with a reviewing function. In other words
            the panel would consider an appeal on the basis of whether the
            process put in place by the PCT had been properly followed and
            consider any new evidence available which was not taken into account
            by the original panel.
           Establish an appeals panel as a rehearing panel i.e. the appeals panel
            would look again at the case and all of the evidence used by the
            original panel and would reach its own decision.

It is proposed that the PCT establishes an appeals panel and that the terms of
reference (Appendix 2) set out that the panel will be a reviewing panel. This
option is recommended as there is already a high level of clinical input into the
decision of the original panel and there would therefore be no necessity to rehear
the case in full. In addition it would force the appeals panel to focus on the issues
which a court would examine in judicial review.

The Appeals Panel provides an opportunity to remedy any deficiencies, errors or
misinterpretations in the decisions taken by the Continuing Care or Exceptions
Panels.

An appeal my be submitted by the patient, the referring clinician or the patient’s
designated representative (validated by receipt of express written consent from
the patient, evidence of enduring power of attorney, evidence of lasting powers of
attorney (under the October 2007 Mental Capacity Act) or evidence of parental
responsibility (in the case of acute exceptions only)1.

Appeals must be received by the PCT in writing within 28 days of the
communication regarding the outcome of the decision of the Exceptions and
Continuing Care Panels.




1Local Authorities wishing to challenge the NHS Continuing Care Panel decision should refer to
the local dispute resolution process.
Criteria for reaching decisions

The threshold criteria for reaching decisions are included in each of the clinical
policies listed in Appendices 3 and 4. In order to apply the criteria to each case
under consideration the panels would need evidence related to:

          The nature and seriousness of the illness or condition which is
           proposed to be treated
          The clinical evidence for and against the requested treatment in
           comparison with any available alternatives
          The guidance contained within current policies and exceptions to those
           policies
          The proposed treatment and its likely effectiveness
          The likely outcome for the individual patient
          The cost of the treatment
          Why it could not be dealt with using care pathways already
           commissioned
          Any NICE, National Specialist Commissioning Advisory Group or
           Department of Health guidance in respect of the treatment
          Why the individual patient is an exceptional case (judged against the
           cohort of patients with that particular condition and not against the
           population generally)
          Any non clinical social factors which are of direct relevance

The clinical policies will be made available to members of the public via the
PCT’s website:

www.brightonhovecitypct.nhs.uk/healthylives/medicalpolicies/index.asp

Procedure

Continuing Care Cases
From 1st October 2007 the “National Framework for NHS Continuing Health care
and NHS funded care” will apply in respect of continuing care cases under
consideration. This framework requires the PCT to fund any case which meets
the criteria. The Continuing Care Panel will therefore decide on individual
eligibility based on whether the criteria are met. The panel will also review cases
already funded to ensure that eligibility criteria are still met. The panel will
formally record all decisions taken in the minutes of the meeting.

Patients, their relatives or carers, clinicians or social care professionals may
submit a case for consideration. Any appeals against a decision made by the
panel will be referred to the PCT’s Appeals Panel for review. It is the
responsibility of the person submitting the appeal to provide details of the appeal
and the evidence to support it but with a full understanding of and access to the
criteria which apply.

Exceptions Cases
Three tiers are proposed for handling applications for funding on an exceptional
basis:

      Tier 1:   Nominated individuals in the PCT with delegated authority to
                authorise straightforward requests for referrals outside of
                existing contracts or the prescribing of particular treatments.
                The nominated individuals are the relevant Strategic
                Commissioner, Executive Directors of Commissioning or Public
                Health, the Head of Medicines Management or a senior
                Prescribing Advisor.

                The cases which would fall into tier 1 would be:

                -   Application of existing commissioning policies or the
                    redirection of uncomplicated referrals
                -   Unavoidable or emergency cases requiring an urgent
                    decision
                -   Unavoidable cases where admission or treatment has
                    already occurred because of the severity of the patient’s
                    needs
                -   Any case where a delay would be substantially detrimental
                    to the patient’s well being (in some cases it may be more
                    appropriate to convene an urgent panel meeting)

                In all cases the decision will be formally recorded in writing and
                submitted to the Exceptions Panel.

      Tier 2:   The Exceptions Panel considers all cases which do not fall into
                Tier 1 and reviews all Tier 1 decisions. Cases must be
                supported by the referring clinician together with the appropriate
                evidence. All decisions taken will be formally recorded as part of
                the minutes of the panel meeting. In reviewing decisions taken
                at Tier 1 the panel will consider whether they were appropriate
                and use them to guide future decisions.

      Tier 3:   As with the continuing care panel mechanism a decision on an
                individual case may be appealed via the Appeals Panel.

The PCT will inform the patient, relative, carer, advocate and clinician or
professional involved in the case of the decision setting out the reasons for the
decision. The Appeals Panel is the final arbiter of a decision in the PCT.
Individual’s may still wish to avail themselves of the NHS complaints procedure
or request a judicial review.

The continuing care criteria, the clinical policies and the details of the decision
making and appeals process will be made available to the public via the PCT’s
website. Advice, support and signposting would be available to individuals by the
PCT’s Patient Advice and Liaison Service (PALS) or the Appeal’s Panel Co-
ordinator.
                                                                     Appendix 2

            Brighton and Hove City Teaching Primary Care Trust
                   Exceptions Panel Terms of Reference

Purpose

The PCT will establish an Exceptions Panel which will consider applications for
funding for patients registered with a Brighton and Hove City GP or who reside
within the boundary of Brighton and Hove where their needs fall outside of the
PCT’s commissioning portfolio.

Constitution

The Exceptions Panel is established as a Sub Committee of the Integrated
Governance Committee.

Membership

The Panel members shall be:

   Strategic Commissioner for Assessment Services (Chair)
   Public Health Consultant
   GP
   Acute services commissioner
   Prescribing Advisor (for relevant cases)

The PCT’s Placement and Referrals Officer and the Administrative Officer
(minutes) will normally be in attendance at the meetings. The Panel may invite
other Directors and senior managers as required.

Quorum

A quorum shall be three members including a GP and a Public Health
representative.

Frequency of Meetings

Meetings shall be held weekly in order to ensure that there is a timely response
to all funding requests.

Authority

The Panel has delegated authority from the Board via the Integrated Governance
Committee to consider and reach decisions on any Tier 2 requests for funding for
individuals whose needs cannot be met from within the commissioning portfolio
of the PCT. The Panel is authorised to obtain outside legal or other independent
professional advice and to secure the attendance of outsiders with relevant
experience and expertise if it considers it necessary.

Responsibilities

The Panel shall:

   Consider and reach decisions on whether to fund individual applications for all
    cases which do not fall into Tier 1 in respect of:
           Out of area referrals not covered by the PCT’s commissioning
              arrangements
           Treatments excluded by the PCT’s clinical policies where funding
              will be considered on an individual exceptional basis
           New drugs or treatments which have or have not been appraised
              by NICE
           Treatments available from independent providers where these are
              not otherwise available through the PCT’s portfolio of
              commissioned services
   Review all decisions taken in Tier 1.

Reporting

The minutes of the Panel shall be formally recorded and submitted in
anonymised form to the Integrated Governance Committee.

Author                          Terry Baker, Director of Assurance and Development
                                  th
Date approved                   11 March 2008
Review date                     March 2009
              Brighton and Hove City Teaching Primary Care Trust
                   Continuing Care Panel Terms of Reference

Purpose

The Panel will consider applications for the funding of individual continuing care
cases2 in accordance with the National Framework for NHS Continuing
Healthcare and NHS Funded Nursing Care (2007).

Constitution

The Continuing Care Panel is established as a Sub Committee of the Integrated
Governance Committee.

Membership

The Panel members shall be:

           Strategic Commissioner for Assessment Services (Chair)
           Public Health Consultant
           GP
           Lead commissioner
           Social work senior manager
           Prescribing Advisor (for relevant cases)

The Placement and Referrals Officer and Administrative Officer (minutes) will
normally attend the meetings. Members of the PCT’s funded nursing care team
will be invited to attend as required to present cases to the panel. The Panel may
co-opt other Directors and senior managers as required.

Quorum

A quorum shall be three members including a GP and Public Health
representative.

Frequency of Meetings

Meetings shall be held weekly to ensure a timely response to all funding
decisions.

Authority



2  Continuing care is care provided over an extended period of time to a person aged 18 or over to
meet physical or mental health needs which have arisen as a result of disability, accident or
illness.
The Panel has delegated authority from the Board via the Integrated Governance
Committee to consider and reach decisions on the funding of individual
continuing care requests. The Panel is authorised to obtain outside legal or other
independent professional advice and to secure the attendance of outsiders with
relevant experience and expertise if it considers it necessary.

Responsibilities

The Panel shall:

   Consider applications for funding for patients assessed as being potentially
    eligible for NHS continuing care.
   Reach decisions on whether the applications received meet the eligibility
    criteria.
   Consider and reach decisions in respect of ongoing funding for people
    already in receipt of NHS continuing care services.
   Reach decisions on the funding of specialist equipment for patients in receipt
    of NHS continuing care services.

Reporting

The minutes of the Continuing Care Panel shall be formally recorded and
submitted in anonymised form to the Integrated Governance Committee.

Author                          Terry Baker, Director of Assurance and Development
                                  th
Date approved                   11 March 2008
Review date                     March 2009
              Brighton and Hove City Teaching Primary Care Trust
                       Appeals Panel Terms of Reference
Purpose

The Appeals Panel considers all appeals received by the PCT against the
decisions of the Continuing Care and Exceptions Panels.

Constitution

The Appeals Panel is established as a Sub Committee of the Board.

Membership

The Panel members shall be:

           Director of Assurance and Development (Chair)
           Director of Public Health
           Non Executive Director
           Director of Quality and Engagement
           GP
           Head of Assurance

The PCT’s Strategic Commissioner, Assessment Services and the Appeals
Panel Co-ordinator will normally attend the meetings. The Committee may invite
other Directors and senior managers as required.

All of the Panel members must be independent of any of the original decision
making processes.

Quorum

A quorum shall be four members which must include a Non Executive Director,
an Executive Director and a GP.

Frequency of Meetings

Meetings shall be scheduled every 6 weeks and will meet whenever there is an
appeal to be considered.

Authority

The Panel has delegated authority from the Board to consider all appeals in
respect of continuing care and acute exceptions cases. The Panel is authorised
to obtain outside legal or other independent professional advice and to secure
the attendance of outsiders with relevant experience and expertise if it considers
it necessary.
Responsibilities

The Panel shall:

   Review the decisions of the PCT’s Exceptions and Continuing Care Panels in
    respect of the funding of individual cases ensuring that the PCT’s process for
    reaching decisions has been followed.
   The Panel will also consider whether there is any new evidence available to it
    which was not considered by the original decision making panel.
   The Panel may:
        Confirm and uphold the original decision taken
        Reverse the original decision if it considers that due process was not
          observed
        Refer the case back to the original decision making panel to reconsider
          the case in the light of new evidence or additional evidence being
          required
   The Panel will ensure that its decision is communicated to the appellant within
    5 days of the panel meeting.

Reporting

The minutes of the Appeals Panel shall be formally recorded and submitted in
anonymised form to the Board.

Author                          Terry Baker, Director of Assurance and Development
                                  th
Date approved                   11 March 2008
Review date                     March 2009
                                                                                      Appendix 3

                           List of Policies Approved by the PCT

1. Policies approved by the PEC
                            POLICY                                  Date Produced     Date approved
                                                                                         by PEC
The National Framework for NHS Continuing Healthcare                 01/10/2007       Department of
and NHS-funded Nursing Care                                                            Health Policy
In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm                06/2006           06/2006
Injection (ICSI) Treatment for patients of PCTs in East
Sussex and Brighton & Hove 2006/07

Supporting documentation for Brighton and Hove PCT IVF                 02/2005          08/02/2005
Policy: Criteria for NHS funded treatments for assisted
conception for the PCTs within Surrey and Sussex

Inosine Pranobex for Chronic                                           06/2005          14/06/2005
Fatigue Syndrome or Chronic Epstein Barr Virus Infection –
recommendation not to fund
Statin Product Choice for Primary and Secondary                        07/2006          10/10/2006
Prevention of CVD

Managing the NHS and private practice interface                        05/2007          26/06/2007

Referral and treatment criteria for varicose vein surgery              04/2007          24/04/2007

Uterine artery embolisation for the treatment of fibroids              07/2006          12/07/2006

Varenciline as an aid to smoking cessation policy                      03/2007          24/04/2007

Inhaled Insulin for the Treatment of Type 1 and Type 2                 09/2006          12/09/2006
Diabetes.
Rimonabant for the treatment of obese, or overweight                   09/2006          12/09/2006
patients with associated risk factors

Morbid Obesity Policy – superseded by NICE Clinical                    01/2007          30/01/2007
Guideline on Obesity

Use of surgery to aid weight reduction in people with
morbid obesity – eligibility criteria for bariatric surgery

2. East Sussex, Brighton and Hove Health Authority Policies adopted by
the PCT
                      POLICY                             Date         Comment
                                                         Produced
Cochlear Implantation Policy                             1995         Will be superseded by Prior
                                                                      Approval document 2008,
                                                                      NICE guidance expected June
                                                                      2008

Dental Implants Policy                                   2000         Will be superseded by Prior
                                                                      Approval document 2008
Policy on referrals to the learning assessment       1995          Superseded       by     NICE
centre Horsham for ADHD etc                                        Technology Appraisal 98
Beta interferon in multiple sclerosis                1996          Superseded by NICE Clinical
                                                                   Guideline 8 2004

Reversal of male and female sterilisation            1995          Will be superseded by Prior
                                                                   Approval document 2008
Tuneable Dye laser Treatment in Dermatology          1997          Will be superseded by Prior
                                                                   Approval document 2008
Complementary therapies - homeopathy and             1999          Will be superseded by Prior
acupuncture                                                        Approval document 2008
Gender reassignment policy                           1995          Will be superseded by Prior
Subsidiary guidance                                  2004          Approval document 2008, and
                                                                   by Gender Dysphoria policy in
                                                                   consultation.


3. Policies approved in draft by the PEC subject to consultation
                  POLICY                         Date              PEC approval
                                                 Produced
Gender Dysphoria – assessment and                In consultation   Draft to PEC Sept 06
treatment policy 2007                            with the public   Endorsed
                                                                   24 July 07
                                                                                  Appendix    4

          List of policies in draft subject to approval by the Board based on the
            recommendations of the Professional Executive Committee (to be
                              discussed by PEC in March 2008

                          PROCEDURE                                        POLICY
Abdominoplasty/apronectomy*                              Cosmetics Policy
Acne scarring                                            * specified on aesthetics list agreed by
Body contouring                                          PEC and Board 2004
Brachioplasty*
Breast augmentation *
Breast reduction *
Brow lift*
Buttock lift*
Calf implants
Chemical peels
Correction of inverted nipple*
Dermabrasion of skin*
Electrolysis
Excision of redundant skin or fat*
Face lift*
Gynaecomastia *
Hair transplant/graft *
Hirsutism treatments
Liposuction*
Mastopexy*
Minor irregularities of aesthetic significance
Neck lift
Plastic operations on umbilicus*
Refashioning of scar*
Skin grafts for scars
Submental lipectomy
Tattooing of skin*
Tattoo removal *
Thigh lift*
Traumatic clefts due to avulsion of body piercing
Upper arm reduction*
Viral wart removal [no restriction on genital warts]
Laser therapy for aesthetic reasons, tunable dye laser   PCT and East Sussex, Brighton and Hove
                                                         Health Authority historic policy
Referral to secondary or tertiary care for alternative
therapies                                                PCT and East Sussex, Brighton and Hove
Aromatherapy                                             Health Authority historic policy covers
Chinese medicines                                        homeopathy and acupuncture
Chiropractic therapy
Clinical ecology
Glucosamine
Herbal remedies
Homeopathy
hypnotherapy
Osteopathy
Reflexology

Massage                                              Massage for primary lymphoedema funded
                                                     on referral from vascular surgeons
Dental
Asymptomatic impacted third molars                   Dental extractions and dental guidelines
Dental extraction of non-impacted teeth              were discussed with dentists and
Dental implants                                      consultants from St. Richards Hospital,
Periapical surgery                                   Worthing Hospital and Queen Victoria
                                                     Hospital.
                                                     Some procedures covered by historic
                                                     polices e.g. dental implants and NICE
                                                     guidance on impacted molars.
Ophthalmology
Blepharoplasty *
Chalazia                                             Criteria for funding stated
Laser surgery for short sight                        Not funded
Eyelid surgery                                       Not funded for cosmetic purposes; for
                                                     ectropion and entropion will be funded
Ptosis of eyelid*                                    Funded where visual field defect confirmed
Xanthelasma
Urology
Circumcision – children and adults                   Criteria for funding established
Penile implants
Retractile penis surgery

ENT
Cochlear implants [unilateral] children and adults   Criteria advanced from earlier East Sussex
Grommets – children                                  Brighton and hove Health Authority policy
Pinnaplasty*
Rhinophyma*
Rhinoplasty/septorhinoplasty*
Repair of lobe of external ear*
Tonsillectomy for children and adults                SIGN criteria

Gynaecology
D&Cs                                                 DH indicator of excess surgical activity
                                                     Not funded for diagnosis or treatment of
                                                     dysfunctional bleeding

Female sterilisation
Dermatology

Basal Cell papillomas
Chalazia [meibomian cysts]                           Criteria for funding established
Removal of benign skin lesions                       Only where concern regarding malignancy

Orthopaedics
Dupuytren’s contracture
Ganglion of wrist
Trigger finger

Botulinum toxin injections                           Supported for use in blepharospasm,
                                                     cervical dystonia, hemifacial spasm
Gender reassignment procedures                       Gender Dysphoria policy – East Sussex,
                                                Brighton and Hove Health Authority
                                                Clarifies that there should be no consultant
                                                to consultant referrals on non-core
                                                procedures. Added to core procedures
                                                from policy:
                                                     Hair removal from surgical sites
                                                     Replaced definition of real life
                                                         experience with the one from the
                                                         draft Standards of Care – Royal
                                                         College of Psychiatry

Hyperbaric oxygen for wound healing             Insufficient evidence for benefit
Private limb prosthesis
Private treatment on NHS                        Based on Department of Health and BMA
                                                guidance
Reversal of vasectomy or female sterilisation
Varicose veins

Vertebroplasty                                  Criteria for funding stated – NICE
                                                interventional procedure guidance
Electronic spinal implants

				
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