Annex A

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					INDIVIDUAL FUNDING REQUEST COMMISSIONING POLICIES STATEMENTS


ANNEX 1                Bariatric Surgery
ANNEX 2                Osseo-integrated dental implants
ANNEX 3                Ear Care Guidance
ANNEX 4                Myringotomy (grommets) in children
ANNEX 5                Tonsillectomy
ANNEX 6                IVF
ANNEX 7                Varicose Veins
ANNEX 8                Caesarean section
ANNEX 9                Dilation and curettage
ANNEX 10               Hysterectomy
ANNEX 11               Ganglion Referral
ANNEX 12               Plastic and Dermatological Procedures
ANNEX 13               Breast Surgery
ANNEX 14               Botulinum Toxin for Hyperhidrosis
ANNEX 15               Laser Surgery
ANNEX 16               Circumcision
ANNEX 17               Septorhinoplasty
ANNES 18               Needle phobia




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                                                                     Annex 1: Bariatric Surgery

                               PRIOR APPROVAL IS REQUIRED

                        THIS POLICY RELATES TO ALL PATIENTS


NHS Bath and North East Somerset

Policy Statement: Bariatric Surgery

Date of Issue: October 2009

Criteria to Access Treatment

NHS BaNES follows NICE guidance and uses the following eligibility criteria:

      the patient has a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and
       other significant disease (for example, type 2 diabetes or high blood pressure) that
       could be improved if they lost weight
      all appropriate non-surgical measures have been tried but have failed to achieve or
       maintain adequate, clinically beneficial weight loss for at least 6 months
      the person has been receiving or will receive intensive management in a specialist
       obesity service
      the person is generally fit for anaesthesia and surgery
      the person commits to the need for long-term follow-up

Full NICE guidance on the care pathway can be accessed at http://www.nice.org.uk/CG43

The GP should be satisfied that all avenues of non-surgical management have been pursued
and that the patient has accessed conventional weight loss programmes. The GP should be
confident that the patient is psychologically able to tolerate the long term side effects of
surgery and understands that surgery is not a cure for weight management but only part of
the weight loss process. The GP should be satisfied that the patient will follow dietary advice
after the surgery has been completed.

NICE have said that surgery should be undertaken only after an assessment of factors that
may affect adherence to postoperative care requirements, such as changes to diet. To be
considered for surgery patients will need to have demonstrate that they can make
appropriate behavioural and lifestyle changes, and adhere to dietary advice. A reduction in
weight as part of a planned programme of dietary and lifestyle changes would be one way to
demonstrate this.

Evidence of the steps in the care pathway that the patient has undergone prior to a request
for bariatric surgery are required as part of the prior approval process. These steps include
participation in a weight management programme under the supervision of a dietician or GP
or membership of a weight loss organisation with evidence that the programme has been
followed for a minimum of 6 months and evidence of pharmaceutical management (if
appropriate).


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Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.


Approved by (committee)        PEC
Date Approved:                 October 2009
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2012




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                                                            Annex 2: Dental Implants

                 HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA

                        THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset

Policy Statement: Osseo-integrated dental implants

Date of Issue: September 2010


This is considered a low clinical priority procedure and is only commissioned with
patients with congenital abnormalities, cancer and trauma.

Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2013




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                                                                              Annex 3: Ear Wax




Ear Care Guidance

Compiled by Hilary Harkin on behalf of Action On ENT

Cerumen Management

Wax or cerumen is a normal secretion of the ceruminous glands in the outer meatus. It is
slightly acidic, giving bactericidal qualities in both its wet, sticky form (as secreted by
Caucasians and Afro-Caribbean’s) or dry, flaky form (as secreted by Orientals). In addition to
epithelial migration, jaw movement assists the movement of wax to the entrance of the ear
canal where it comes out on to the skin. A small amount of wax is normally found in the ear
canal and its absence may be a sign that dry skin conditions, infection or excessive cleaning
has interfered with the normal production of wax. It is only when there is an accumulation of
wax that removal may be necessary. A build-up of wax is more likely to occur in people who
insert implements into the ear, have narrow ear canals, hearing aid users, older adults and
patients with learning difficulties. A build-up of wax may also occur with anxiety, stress and
dietary or hereditary factors. Excessive wax should be removed before it becomes impacted
giving rise to tinnitus, hearing loss, vertigo, pain and discharge. If wax is removed due to the
presenting complaint of hearing loss, ascertain whether good hearing is restored after
treatment or if the patient would benefit from a formal assessment by the ENT surgeon or
Audiologist. Providing they meet certain criteria stated in local referral guidelines older adults
with a bilateral hearing loss can be referred directly to the Audiology Department.

The experienced practitioner can use his or her clinical judgment on the best method for ear
examination and wax removal. These recommendations have been developed to assist
practitioners in gaining experience and knowledge in the provision of ear care. They do not
replace the need for education, training and supervision in order to perform these
procedures.

Guidance for ear examination

1. Before careful physical examination of the ear, listen to the patient, elicit symptoms and
take a careful history. Explain each step of any procedure or examination and ensure that the
patient understands and gives consent. Ensure that both you and the patient are seated
comfortably, at the same level, and that you have privacy.

2. Examine the pinna, outer meatus and adjacent scalp. Check for previous surgery incision
scars, infection, discharge, swelling and signs of skin lesions or defects. Decide on the most
appropriate sized speculum that will fit comfortably into the ear and place it on the auriscope.

3. Gently pull the pinna upwards and outwards to straighten the ear canal. (Directly down
and back in children). Localized infection or inflammation will cause this procedure to be
painful so do not continue.

4. Hold the auriscope like a pen and rest the small digit on the patients’ head as a trigger for
any unexpected head movement. Use the light to observe the direction of the ear canal and
the tympanic membrane. There is improved visualisation of the ear drum by using the left
hand for the left ear and the right hand for the right ear but clinical judgment must be used to

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assess your own ability. Insert the speculum gently into the meatus to pass through the hairs
at the entrance to the canal.

5. Looking through the auriscope check the ear canal and tympanic membrane. Adjust your
head and the auriscope to view all of the tympanic membrane. The ear cannot be judged to
be normal until all the areas of the membrane are viewed; the light reflex, handle of malleus,
pars flaccida, pars tensa and anterior recess. If the ability to view all of the tympanic
membrane is hampered by the presence of wax, then wax removal will have to be carried
out.

6. If the patient has had canal wall down mastoid surgery, methodically inspect all parts of
the cavity, tympanic membrane or drum remnant by adjusting your head and the auriscope.
The mastoid cavity cannot be judged to be completely free of ear disease until the entire
cavity and tympanic membrane or drum remnant has been seen.

7. The normal appearance of the membrane or mastoid cavity varies and can only be
learned by practice. Practice will lead to recognition of abnormalities.

8. Carefully check the condition of the skin in the ear canal as you withdraw the auriscope. If
there is doubt about the patient’s hearing an audiological assessment should be made.
Providing they meet certain criteria stated in local referral guidelines older adults with a
bilateral hearing loss can be referred directly to the Audiology Department.

9. Document what was seen in both ears, the procedure carried out, the condition of the
tympanic membrane and external auditory meatus and treatment given. Findings should be
documented with Nurses following the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT Outpatient Department
following local policy.

Guidance on the use of syringes in the ear

The metal syringe is obsolescent for use in the ear canal. The syringe design is inherently
dangerous. Combined with the danger of the syringe itself and the pressure of water it
creates within the ear canal, there is the difficulty of disinfecting the syringe after each use.
The Medical Devices Agency (MDA) also has reservations about the use of the metal syringe
for wax removal. There are issues around the poor manufacture of some syringes allowing
them to break and cause injury during use and the pressure of water that can be exerted
manually on the tympanic membrane.

Electronic irrigators such as the "Propulse" and the "Otoscillo" allow irrigation of the ear canal
rather then wax removal under pressure. The MDA issued Safety Notice SN 9807 in
February 1998 that advised users that the original Propulse electronic irrigator required an
isolation transformer for electrical safety. Subsequently, the manufacturer designed and
marketed the Propulse II to replace the original Propulse. This guidance document
recommends that practitioners use an electronic ear irrigator rather than the manual syringe
and refer to the procedure as ear irrigation.

The Propulse II irrigator has a pressure variable control of minimum maximum, allowing the
flow of water to be easily controlled by commencing irrigation on the minimum setting. For
patient safety, Propulse has limited the maximum pressure available; this limit is stated in the
user instructions. The propulse II irrigator has specific disinfecting guidelines issued with
approval from infection control committees.

The only other equivalent device available on the British market is the German ear irrigator
called the Mulimed-Otoscillo irrigating jet machine. The numbers one to six denotes the

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pressure control but, as the manufacturer does not state a maximum limit, it is difficult to
assess the maximum pressure developed by the irrigator. There is no evidence promoting
this machine as an ear irrigator and there is no documentation about the safe pressure
exerted by the machine. A further failing is that the design of the irrigator tip does not offer
the preferred direction against the posterior ear canal wall. The manufacturers of the
Mulimed-Otoscillo do not recommend a specific solution to disinfect the irrigating machine.
This has the danger of users using inappropriate solutions and the machine harbouring
infection.

The Welch Allyn Ear Wash System is an American irrigator that attaches to a combined hot
and cold water tap. There are problems in the United Kingdom with attachment to a number
of taps found within the community and hospital setting. It is of comparable price to both the
electronic irrigators but there may be the added cost of having the tap changed to a suitable
model. The system can not be used in rooms where there is no access to water as in
patients confined to a sitting room within a nursing home or community setting. It does limit
the maximum amount of water pressure exerted in the ear and controls variation in the flow
of water. If there is an increase/ decrease in the temperature of water the machine will stop
the flow of water until it is altered. This machine has a suction system, which returns the
discharge and debris away from the ear and can be used without the flow of water to remove
the remaining moisture from the ear canal.

GUIDANCE FOR EAR IRRIGATION USING THE ELECTRONIC IRRIGATOR

This procedure is only to be carried out by a trained doctor, nurse or audiologist.

PRINCIPLES - Irrigating the ear is carried out to: -

      Facilitate the removal of cerumen and foreign bodies which are not hygroscopic, from
       the external auditory meatus. Hydroscopic matter (such as peas and lentils will
       absorb the water and expand making removal more difficult

      Remove discharge, keratin or debris from the external auditory meatus

An individual assessment should be made of every patient to ensure that they are
appropriate for ear irrigation to be carried out.

REASONS for using this procedure - In order to: -

      Correctly treat otitis externa where the meatus is obscured by debris

      Improve conduction of sound to the tympanic membrane when it is blocked by wax

      Remove debris to allow examination of the external auditory meatus and the
       tympanic membrane.

Irrigation should not be carried out when: -

      The patient has previously experienced complications following this procedure in the
       past

      There is a history of a middle ear infection in the last six weeks.

      The patient has undergone ANY form of ear surgery (apart from grommets that have
       extruded at least 18 months previously and the patient has been discharged from the
       ENT dept)

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      The patient has a perforation or there is a history of a mucous discharge in the last
       year

      The patient has a cleft palate (repaired or not)

      In the presence of acute otitis externa; an oedematous ear canal combined with pain
       and tenderness of the pinna


REQUIREMENTS
Auriscope
Head mirror and light or head light and spare batteries
Electronic irrigator
Jug containing tap water to 40o
Noots trough/receiver
Jobson Horne probe and cotton wool
Tissues and receivers for dirty swabs and instruments
Waterproof cape and towel

THIS PROCEDURE SHOULD BE CARRIED OUT WITH BOTH PARTICIPANTS SEATED
AND UNDER DIRECT VISION, USING A HEADLIGHT OR HEAD MIRROR AND LIGHT
SOURCE, THROUGHOUT THE PROCEDURE.

PROCEDURE
1. Informed consent should be obtained prior to proceeding.

2. Examine both ears by first inspecting the pinna, outer meatus (ear canal) and adjacent
scalp by direct light. Check for previous surgery incision scars or skin defects, then inspect
the external ear with the auriscope.

3. Check whether the patient has had his ears irrigated previously, or if there are any
contraindications why irrigation should not be performed.

4. Explain the procedure to the patient and ask the patient to sit in an examination chair with
their head tilted towards the affected ear. (A child could sit on an adult's knee with the child's
head held steady).

5. Place the protective cape and towel on the patient’s shoulder and under the ear to be
irrigated. Ask the patient to hold the receiver under the same ear.

6. Check your headlight is in place and the light is directed down the ear canal. Check that
the temperature of the water is approximately 40°C and fill the reservoir of the irrigator. Set
the pressure at minimum.

7. Connect clean jet tip applicator to tubing of machine with firm push/twist action. Push until
"click" is felt.

8. Direct the irrigator tip into the noots receiver and switch on the machine for 10-20 seconds
in order to circulate the water through the system and eliminate any trapped air or cold water.
This offers the opportunity for the patient to become accustomed to the noise of the machine
and for you to ensure the temperature of water at the tip is approximately 37°C. The initial
flow of water is discarded, thus removing any static water remaining in the tube.



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9. Twist the jet tip so that the water can be aimed along the posterior wall of the ear canal
(towards the back of the patient’s head).

10. Gently pull the pinna upwards and outwards to straighten the ear canal. (Directly
backwards in children).

11. Warn the patient that you are about to start irrigating and that the procedure will be
stopped if they feel dizzy or have any pain. Place the tip of the nozzle into the ear canal
entrance and using foot control direct the stream of water along the roof of the ear canal and
towards the posterior canal wall (directed towards the back of the patient’s head). If you
consider the entrance to the ear canal as a clock face you would direct the water at 11
o’clock on the right ear and 1 o’clock on the left ear. Increase the pressure control gradually if
there is difficulty removing the wax. It is advisable that a maximum of two reservoirs of water
is used in any one irrigating procedure.

12. If you have not managed to remove the wax within five minutes of irrigating, it may be
worthwhile moving onto the other ear as the introduction of water via the irrigating procedure
will soften the wax and you can retry irrigation after about 15 minutes.

13. Periodically inspect the ear canal with the auriscope and inspect the solution running into
the receiver.

14. After removal of wax or debris, dry mop excess water from meatus under direct vision
using the Jobson Horne probe and best quality cotton wool. Stagnation of water and any
abrasion of skin during the procedure predispose to infection. Removing the water with the
cotton wool tipped probe reduces the risk of infection.

15. Examine ear, both meatus and tympanic membrane and treat as required following
specific guidelines or refer to doctor if necessary.

16. Give advice regarding ear care and any relevant information.

17. Document what was seen in both ears, the procedure carried out, the condition of the
tympanic membrane and external auditory meatus and treatment given. Findings should be
documented with Nurses following the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT Outpatient Department
following local policy.

NB IRRIGATION SHOULD NEVER CAUSE PAIN. IF THE PATIENT COMPLAINS OF PAIN
- STOP IMMEDIATELY.

ALWAYS USE A CLEAN SPECULUM, JET TIP APPLICATOR AND PROBE FOR EACH
PATIENT.

It is recommended that you follow the manufacturer guidelines for cleaning and
disinfecting the irrigator and its components




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GUIDANCE FOR AURAL TOILET
Principles - aural toilet is used to clear the aural meatus of debris, discharge, soft wax or
excess fluid following irrigation.

This procedure is only to be carried out by a trained doctor, nurse or audiologist.

An individual assessment should be made of every patient to ensure that they are
appropriate for aural toilet to be carried out.

1. Examine the ear.

2. Dry mop - Using a Jobson Horne probe and a small piece of fluffed up cotton wool, the
size of a postage stamp, applied to the probe. Under direct vision (with headlight or head
mirror and light) and pulling the pinna to straighten the canal, clean the ear with a gentle
rotary action of the probe. Do not touch the tympanic membrane.

3. Replace the cotton wool directly it becomes soiled. Pay particular attention to the anterior-
inferior recess, which can harbor debris.

4. Re-examine the meatus intermittently, using the auriscope, during cleaning to check for
any debris/discharge/crusts which remain in the meatus at awkward angles.

5. Patients who have mastoid cavities should be followed up in the ENT department unless
the nurse, doctor or audiologist has been specifically trained in this area. The frequency of
cleaning required by the cavity will depend on the individual patient. If the cavity gets
repeatedly infected the patient should be considered for revision surgery.

6. If an infection is present treatment should follow patient group directives and referral
guidelines or as dictated by the result of a swab culture and sensitivities following the failure
of first line management. If the patient has repeated problems with the ear, an ENT Surgeon
should review them.

7. Give advice regarding ear care and any relevant information.

8. Document what was seen in both ears, the procedure carried out, the condition of the
tympanic membrane and external auditory meatus and treatment given. Findings should be
documented with Nurses following the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT Outpatient Department
following local policy.

GUIDANCE FOR REMOVAL OF EXCESSIVE WAX

This procedure is only to be carried out by a trained doctor, nurse or audiologist.

They are to be used as a guide: when the practitioner has developed their skills they can use
their own clinical judgment on the most appropriate method and instrumentation to remove
wax.

1. Examine the ear to discern the type of wax to be removed. Ask yourself is this healthy wax
or may it be bacterial debris of wax like appearance. Is it dry crumbly wax related to
Seborrhea Dermatitis? Is it soft, beige wax in both ears that can be associated with high
cholesterol?

2. Hard, crusty wax can often be gently manoeuvred out of the meatus with a ring probe,
using a head mirror or light for illumination. Experienced practitioners may prefer to use a

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wax hook or forceps. If this treatment becomes painful, do not continue as the mealal lining
quickly becomes traumatised, so risking infection. Instruct the patient according to your
clinical judgment. A possible treatment could be to use olive oil or sodium bicarbonate
inserted correctly for up to 1 week. The patient can then return for irrigating or further
instrumentation. Excessive soft wax or crumbly wax and debris can be wiped out with cotton
wool wound onto a Jobson Horne probe (using aural toilet guidelines) or irrigated.

3. Cerumenolytic ear drops can be used to break up hard wax but patients may develop
meatal irritation from the astringent qualities of these agents. This is particularly the case with
older adults or people who suffer with dermatology conditions or recurrent otitis externa.

4. If a perforation is suspected behind the wax, advise the patient to use olive oil in very
small amounts, but to stop using it if they experience any pain.

5. Give advice regarding ear care and any relevant information.

6. Document what was seen in both ears, the procedure carried out, the condition of the
tympanic membrane and external auditory meatus and treatment given. Findings should be
documented, with nurses following the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT Outpatient Department
following local policy.


GUIDANCE FOR MICROSUCTION
PRINCIPLES – Use of the microscope and suction is carried out to: -

      Remove cerumen and hygroscopic foreign bodies in patients who are not appropriate
       for ear irrigation.

      Remove discharge, keratin or debris from the external auditory meatus or mastoid
       cavity.

This procedure is only to be carried out by a trained doctor, nurse or audiologist who has
developed the skill of performing the use of the microscope and suction. The suction
generates loud noise and patients sometimes complain of the discomfort of the procedure.

An individual assessment should be made of every patient to ensure that microsuction is
appropriate.

PROCEDURE

1. Before careful physical examination of the ear listen to the patient, elicit symptoms and
take a careful history. Explain each step of any procedure of examination and assure
yourself that the patient understands and gives consent.

2. Check whether the patient has had microsuction previously, explain the nature of the noise
and that they can ask for a rest if they experience any vertigo (if this should occur ask the
patient to focus their eyes on a fixed object until the feeling subsides).

3. Adjust the magnification, eye piece and angle of the microscope to the appropriate
position. Request that the patient position themselves comfortably on the examination couch
or chair.

4. First examine the pinna, outer meatus and adjacent scalp by direct light and check for
incision scars and observe for skin defects.

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5. Gently pull the pinna upwards and outwards (in infants downwards and backwards) to
straighten out the meatus. Remember that the skin lining the deeper meatus is very delicate
and sensitive.

6. Direct the microscope down into the ear. Insert the speculum gently into the cavity - use
the largest size speculum that will fit comfortably into the ear.

7. Carefully check the cavity, tympanic membrane or drum remnant. Decide the size of
suction tip most appropriate for the procedure and attach it to the suction tubing.

8. Turn the suction machine on, maintaining the pressure between 80 to 120mm Hg (18 to 20
cm H2O). Apply the suction tip to the areas requiring debris removal. Use an appropriate
solution to wash through the suction tubing when it becomes blocked.

9. Avoid touching the wall of the meatus, cavity or drum/ drum remnant. By only touching the
debris, most pain can be avoided.

10. The ear cannot be judged to be completely free of ear disease until the entire cavity and
tympanic membrane or drum remnant has been seen. You may need to ask the patient to
move his head e.g. lean head towards the opposite shoulder to be able to see more clearly
into the roof of the meatus and posterior aspect of the cavity.

11. Methodically inspect all parts of the cavity, tympanic membrane or drum remnant by
varying the angle of the microscope.

12. The normal appearance of the cavity varies and can only be learned by practice. Practice
will lead to recognition of abnormalities.

13. Carefully check the condition of the external auditory meatus as you withdraw the
speculum.

14. Advice should be given to the patient as appropriate.

15. Document what was seen in both ears, the procedure carried out, the condition of the
tympanic membrane and external auditory meatus and treatment given. Findings should be
documented with Nurses following the NMC guidelines on record keeping and accountability.
If any abnormality is found a referral should be made to the ENT Outpatient Department
following local policy.




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                                                         Annex 4: Myringotomy (grommets)

                 HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA

                        THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset

Policy Statement: Myringotomy (grommets) in children

Date of Issue: September 2010

This is considered a low clinical priority and access is based on the criteria below taking
account of NICE guidance.

Criteria for access

      NHS B&NES will fund treatment with grommets in children with disabilities such as
       Down’s syndrome and Cleft Palate where the insertion of grommets is part of an
       established pathway of care.
      NHS B&NES will fund treatment with grommets in children to treat a tympanic
       membrane retraction pocket.
      NHS B&NES will fund treatment with grommets in children with Otitis Media with
       Effusion (OME) and without a second disability (such as Down’s Syndrome or Cleft
       Palate) only when:
           o There has been a period of watchful waiting for persistent OME, within a one
               year period from diagnosis of OME.
           o There are documented concerns about speech and language delay or
               behavioural problems affecting the child related to the ear problems.
           o The child has documented hearing level in the better ear of 25-30dBHL or
               worse averaged at 0.5, 1, 2 and 4 kHZ (or equivalent dba where dBHL not
               available).
      NHS B&NES will fund grommet insertion as a preliminary procedure for the
       application of Intra Tympanic Gentamicin in the treatment of Meniere’s disease where
       medical treatment has failed and the disease becomes unremitting leading to
       persistent hearing loss.
      NHS B&NES will fund grommet insertion for children with permanent childhood
       hearing impairment where OME is contributing to a deterioration of normal
       functioning.

Requests for funding outside these criteria will not be funded.
Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2013

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                                                                       Annex 5: Tonsillectomy



                    HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA

                           THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset

Policy Statement: Tonsillectomy


Date of Issue: July 2011


Criteria to Access Treatment

Patients with recurrent sore throat can be referred to ENT consultants for consideration of
tonsillectomy if all the following criteria are met:
              The Sore throats presenting are due to tonsillitis as confirmed by the patients
               GP.
              There have been more than 5 episodes per year of tonsillitis, and these
               episodes have been severe enough to disrupt their normal behaviour or day-
               to-day activity.
              Symptoms have been present for at least a year.
              Episodes of tonsillitis are disabling and prevent normal functioning.
              The benefit of tonsillectomy is judged to be above the potential harms.
NHS B&NES will fund tonsillectomy in children and adults as part of cancer treatment
management.
Patients with the following conditions should be referred to an ENT consultant who will
assess whether surgery is likely to result in a substantial and sustained improvement in
health:
    children and adults with quinsy, if tonsillectomy is considered clinically necessary
    children for obstructive sleep apnoea where other treatments have failed or are
    inappropriate
    to aid the management of other chronic conditions where these are exacerbated by
    acute infective episodes e.g. psoriasis / psoriatic arthritis / febrile convulsions / epilepsy,
    and where there is evidence that these are being exacerbated by tonsillitis
    where there is chronic infection of the tonsils failing to respond to medical management
    (including long term antibiotic treatment of 3-6 months) and where symptoms (of the
    chronic infection) have been present for at least one year.

Prior approval should be sought from the PCT for treatment of adults with sleep disruption
and adults with obstructive sleep apnoea. Applications will be considered where
conservative management has failed, there is evidence that this is preventing normal
functioning, where the problem is proven to be caused by Tonsil hypertrophy and where
benefits will outweigh risks.


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Sore throat associated with stridor or respiratory difficulty is an absolute indication for
admission to hospital.


Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:
Produced by (Title);           Associate Director of Planned Care
Review Date:                   June 2016




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                                                                              Annex 6: Fertility

                 HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA

                        THIS POLICY RELATES TO ALL PATIENTS


NHS Bath and North East Somerset

Policy Statement: IVF

Date of Issue: July 2009


1    Age of Woman          The time of the cycle of IVF / ICSI or ICSI starting should be after
     at time of cycle      the woman’s 23rd birthday and before the woman’s 40th birthday.
     starting
2    Age of woman at       The minimum age at the time of referral is exactly 23 years minus
     time of referral      the maximum likely waiting time. This is to ensure that women
                           whose chances of conception are running out of time will receive a
                           service first. This age limit will not normally be lowered in the case
                           of partners who have medical evidence suggesting that IVF / ICSI
                           will be their only chance of conception because of physical causes
                           which have been discovered earlier.
                           The maximum age at time of referral is exactly 40 years minus the
                           maximum likely waiting time.

3    Age of male           No upper age limit. (Note: No upper age limit in adoption laws for
     partner               male partner)
4    Number of             one cycle of IVF / ICSI will be available on the NHS
     cycles
5    Previous              Any previous NHS funded IVF / ICSI treatment will be an exclusion
     infertility           criterion.
     treatment
                           Couples who have already had 3 or more cycles of IVF / ICSI
                           (privately or NHS funded elsewhere) will not be eligible for further
                           NHS funding.

                           Funding will not be available retrospectively for any couples who
                           would have been eligible but self funded their treatment.




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6    Same sex              Sub fertility treatment will be funded for same sex couples or
     couples/              individuals not in a partnership if those seeking treatment are
     individuals not       demonstrably sub fertile. Cases will be considered by the Primary
     in a partnership      Care Trust. An assessment of sub fertility will made on an
                           individual, case by case basis. The Primary Care Trust will aim to
                           apply the same level of stringency in determining sub fertility for all
                           individuals or couples seeking treatment.

                           In the case of same sex couples in which only one partner is sub
                           fertile, clinicians should discuss the possibility of the other partner
                           receiving treatment before proceeding to interventions involving
                           the sub fertile partner.

                           Same sex couples will be assessed if insemination on at least 10
                           non-stimulated cycles over a period of 2 years has failed to lead to
                           a pregnancy. NHS funding is not available for access to donor
                           insemination facilities for fertile women. All other criteria apply
                           equally.

                           NHS funding will not be available for access to insemination
                           facilities for fertile women who are part of a same sex partnership
                           or those not in a partnership.

                           In circumstances in which those in a same sex partnership or
                           individuals are eligible for sub fertility treatments, the other criteria
                           for eligibility for sub fertility treatments will apply.

                           Same sex couples and individuals should have access to
                           professional experts in reproductive medicine to obtain advice on
                           the options available to them to enable them to proceed along this
                           route if they so wish.

7    Childlessness         Treatments for sub fertility will only be funded for couples with no
                           living child from the current relationship, including adopted
                           children.

                           Once accepted for treatment, should a child be adopted or a
                           pregnancy leading to a live birth occur, other than as a result of the
                           treatment funded by the PCT the couple will no longer be eligible
                           for treatment.
8    Sterilisation         Fertility treatment will not be available if the sub fertility is the result
                           of a sterilisation procedure in either partner.

                           In addition, the surgical reversal of either male or female
                           sterilisation will not be funded except in exceptional circumstances.
9    BMI                   Women must have a BMI of between 19 and 30 inclusive for a
                           period of 6 months or more before receiving any treatment.
                           Women with polycystic ovaries with a BMI between 19 and 33 will
                           be eligible for treatment.

                           They must be informed of this criterion at the earliest possible
                           opportunity in their progress through infertility investigations in
                           primary care and secondary care. GPs should provide
                           unambiguous and clear information to infertile couples.


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                                                                                          Page 17 of 36
10   Smoking               Only non-smoking couples will be accepted on the IVF / ICSI
                           treatment waiting list.
                           They must be informed of this criterion at the earliest possible
                           opportunity in their progress through infertility investigations in
                           primary care and secondary care. GPs should provide
                           unambiguous and clear information to infertile couples.
11   IUI / DI              Eligible patients may choose to have up to 3 cycles of IUI or 3
                           cycles or DI OR one cycle of NHS funded IVF, assuming all parts
                           of these criteria are met.

12   Egg Donation          Egg donation will be funded for women who meet the criteria for
                           IVF, where required

13   HFEA Code of          Couples not conforming to the HFEA’s Code of Practice will be
     Practice              excluded from having access to NHS funded assisted fertility or
                           other treatment. This includes consideration of the ‘’welfare of the
                           child’ which may take into account the pre-existing health status of
                           the parents.

15   Funding               Funding will not be available retrospectively for any couples who
                           would have been eligible but have agreed to self fund their
                           treatment, whether payment has been made in full, part or has yet
                           to be taken.

15   Definition of         NHS funded IVF / ICSI treatment will only be available from the
     BANES                 Bath Fertility Centre. The person receiving treatment must be
     individual            referred from a BANES GP.



Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.




Approved by (committee)        PCT Board
Date Approved:                 July 2009
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2012




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                                                                       Annex 7: Varicose Veins
                  HOSPITAL TO APPROVE IF PATIENT MEETS CRITERA

                        THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset


Policy statement: Varicose Veins


Date of Issue: September 2010


Treatments for varicose veins are considered low clinical priority. Surgical treatment of
varicose veins for cosmetic reasons will not normally be funded. Surgical treatment will only
be provided by the NHS for patients meeting criteria set out below.
Varicose veins are tortuous, distended and bulging veins (varicosities) beneath the skin of
the legs. The majority arise from incompetent long or short saphenous veins. They can be
obscured by oedema and subcutaneous fat.
This intervention is approved according to criteria established in guidelines issued by NICE.

Criteria for Access

Referral should be considered for one or more of the following indications:
      Bleeding from a varicosity that has eroded the skin
      One bleed from a varicosity that is at risk of bleeding again
      Venous ulceration
      Skin changes at the ankle
      Recurrent superficial thrombophlebitis
      Troublesome symptoms from varicose veins where the patient and/or the GP feel that
       the extent, size and site of the varicose veins are causing the patient significant
       functional impairment.


Significant functional impairment is defined as:
      Symptoms prevent the patient fulfilling vital work or educational responsibilities
      Symptoms prevent the patient carrying out vital domestic or carer activities


The patient whose principal complaint in relation to varicose veins is pain should be asked to
wear class II compression hosiery for a period of time and only referred if symptoms are not
fully relieved and continued compression stocking use impractical.


 Patients with asymptomatic or symptomatic uncomplicated varicose veins (i.e. there is no
thrombophlebitis, skin changes, ulceration or bleeding) are unlikely to develop significant
complications of venous disease. Treatment for uncomplicated varicose veins is aimed at
improving quality of life, so if symptoms are not severely affecting quality of life, treatment
should be withheld.

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Investigations in the secondary care setting, e.g. Doppler and photoplethysmography and
duplex scanning should only be performed if criteria for treatment are met.
Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications
cannot be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2013




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                                                                 Annex 8: Caesarian Section

                 HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA

                        THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset

Policy Statement: Caesarean section

Date of Issue: September 2010

Criteria to Access Treatment

This intervention is approved according to criteria established in guidelines issued jointly by
NICE and the National Collaborating Centre for Women’s and Children’s Health.

Planned caesarean section should only be offered to women with:

           o   a term singleton breach (if external cephalic version is contraindicated or has
               failed)
           o   a twin pregnancy with breech first twin
           o   HIV
           o   Both HIV and hepatitis C
           o   Primary genital herpes in the third trimester
           o   Grade 3 and 4 placenta praevia

A planned caesarean section should not be routinely offered to women with:

           o   twin pregnancy (first twin is cephalic at term)
           o   Preterm birth
           o   a “small for gestational age” baby
           o   hepatitis B virus
           o   hepatitis C virus
           o   Recurrent genital herpes at term

Caesarean Section for non-clinical reasons will not be funded. Maternal request is not on its
own an indication for Caesarean Section.
Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.
Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2013




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                                                               Annex 9: Dilation & Curettage


                 HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA
                      THIS POLICY RELATES TO ALL PATIENTS



NHS Bath and North East Somerset

Policy Statement: Dilation and curettage

Date of Issue: September 2010

This procedure is considered a procedure of low clinical priority and is funded on a restricted
basis only. This intervention is approved according to criteria established in guidelines
issued by NICE.

Dilation and curettage alone should not be used as a diagnostic tool and should not be used
as a therapeutic procedure.

Criteria for access
Dilation and curettage is commissioned when the criteria below are met:

        The patient has had outpatient negative pressure endometrial sampling (e.g. Pipelle
         TM
            sampling) with an unsatisfactory result: or

        The patient has had a hysteroscopy and endometrial biopsy with an unsatisfactory
         histological result

D&C may still be used to evacuate products of conception [see www.whbs.org.uk]. This does
not require prior approval. Observational evidence suggests that D&C may cause adverse
effects including uterine perforation and cervical laceration, as well as the usual risks of
general anaesthesia.

Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2012




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                                                                    Annex 10: Hysterectomy


                 HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA

                        THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset

Policy Statement: Hysterectomy

Date of Issue: September 2010

This intervention is approved according to criteria established in guidelines issued by NICE.

Criteria for access

NHS B&NES will fund hysterectomy for heavy menstrual bleeding or dysmenorrhoea if all the
following criteria are met:

   a) Other treatments for heavy menstrual bleeding (in accordance with NICE Clinical
      Guidance 44 ‘Heavy Menstrual Bleeding’) or dysmenorrhoea have failed or are
      contradicted. http://www.nice.org.uk/nicemedia/live/11002/30404/30404.pdf ‘
   b) NHS B&NES will fund hysterectomy for the treatment of uterine problems amenable
      (where surgery is the most appropriate treatment) to surgery that is not related to
      heavy menstrual bleeding or dysmenorrhoea.

In cases when:

      there is a wish for amenorrhoea
      the woman requests it
      the woman no longer wishes to retain her uterus and fertility

Hysterectomy should be offered only after the woman has been fully informed of the other
potential treatments, potential risks, and of side-effects and complications arising with
hysterectomy.

Requests for treatment outside these criteria will not be funded.

Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.


Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2012

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                                                                              Annex 11: Ganglia


                         TREATMENT REQUIRES PRIOR APPROVAL

                         THIS POLICY RELATES TO ALL PATIENTS



NHS Bath and North East Somerset

Policy Statement: Ganglion Referral


Date of Issue: September 2010


Referral of ganglion in secondary care is considered a procedure of low clinical priority and is
funded on a restricted basis only. GPs must obtain prior approval before referring to
secondary care.


Criteria to Access Treatment
Referral for ganglion in secondary care is commissioned on a restricted basis. Cases will
only be funded if they meet the criteria below:

        The ganglion has resulted in significant functional impairment
OR
        The individual is experiencing considerable pain as a result of the ganglion’s size or
         position
OR
        Where there is doubt about the diagnosis (with or without pain)


Significant functional impairment is defined as:
        Symptoms prevent the patient fulfilling vital work or educational responsibilities
        Symptoms prevent the patient carrying out vital domestic or carer activities)

To enable NHS B&NES to approve individual cases, the following information with examples
of significant functional impairment using the guidance below should be provided in the
application form:

Precise location of ganglion e.g. flexor tendon
    Size in cm/inches (length and width)
    How function of the area is impaired? i.e. what is the patient unable to do as a result
       of the ganglion?
    Impact on work/studies/care i.e. is the patient unable to fulfill any work/study/carer
       essential activities and if so to what extent?
    Impact on daily activities i.e. is the patient unable to carry out essential domestic
       activities such as cooking, washing etc?
    Degree of pain
    How long it has existed and treatments tried to date

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Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2015




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                                       Annex 12: Plastic & dermatological procedures

               GP/HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA

                        THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset

Policy Statement: Plastic and Dermatological Procedures

Date of Issue: September 2010

NHS B&NES commissions the use of plastic procedures and dermatological surgery,
where appropriate, for treatment of the following conditions:

      Burns
      Tissue infection
      Trauma (particularly associated with impaired physical function)
      Skin damage (e.g. pressure sores)
      Malignant lesions
      Disfiguring facial lesions
      Endocrine disease complications
      Congenital abnormalities (e.g. cleft lip and palate, hypospadias, hamartoma)
      Port wine stain treatment with pulsed dye laser
      Neurological conditions (e.g. Bell’s Palsy)
      Functional problems which are correctable

Plastic procedures and dermatological surgery outside the above categories are not
commissioned by NHS B&NES, and will not be supported unless there is unequivocal
evidence that the case is exceptional, and that the proposed intervention will be of
significant clinical benefit. (See also Breast Surgery policy).

Skin surgery involving cryotherapy, curettage and cauterisation is commissioned within
primary care contracts and not secondary care. The removal of a benign asymptomatic skin
lesion by surgery, cryotherapy, or laser treatment is regarded as a procedure of low clinical
value. These procedures are therefore not routinely commissioned by NHS B&NES. No
procedures may be undertaken in the NHS for purely cosmetic reasons.

The removal of benign skin lesions is funded on a restricted basis only. Removal of benign
skin lesions is funded if they are causing significant pain, recurrent infection (more than two
episodes), recurrent bleeding (more than two episodes) or are causing significant facial
disfigurement (i.e. lesions on the face where the extent and size of the lesion can be
regarded as disfigurement). Removal of benign skin lesions is not commissioned in
secondary care unless causing significant facial disfigurement.

Procedure                Commissioning position /             Comments
                         approved indication
Naevi and other          Only treat if causing significant    Removal of benign lesions not
benign                   pain, recurrent infection,           commissioned in secondary care
haemangiomas             recurrent bleeding or are facially   unless facially disfiguring.
                         disfiguring                          Occasionally benign lesions may be
                                                              excised in secondary care where they
                                                              have been referred as potentially

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                                                                                     Page 26 of 36
                                                               malignant and these will be charged
                                                               as diagnostic OP/OP procedure.

Dermatofibromas          Only treat if causing significant     Removal of benign lesions not
                         pain, recurrent infection,            commissioned in secondary care
                         recurrent bleeding or are facially    unless facially disfiguring
                         disfiguring
Lipomata                 Only treat if severely functionally   Lipomas on body >5cm in diameter, or
                         disabling, subject to repeated        in sub-fascial position which have also
                         trauma or rapidly growing or          shown rapid growth and/or are painful
                         abnormally located, lesion >          should be referred to an appropriate
                         5cms                                  skin cancer clinic
Sebaceous cysts          Only treat if                         Removal of benign lesions not
                             - on face and greater 1cm         commissioned in secondary care
                                 in diameter                   unless facially disfiguring
                             - greater than 1cm and
                                 associated with
                                 significant pain/loss of
                                 function
                             - recurrent infection
                             - recurrent bleeding
Skin tags                Only treat if causing significant     Removal of benign lesions not
                         pain, recurrent infection,            commissioned in secondary care
                         recurrent bleeding or are facially    unless facially disfiguring
                         disfiguring
Spider naevi             Only treat if causing significant     Removal of benign lesions not
                         pain, recurrent infection,            commissioned in secondary care
                         recurrent bleeding or are facially    unless facially disfiguring
                         disfiguring
Thread veins             Not routinely funded                  Not commissioned in secondary care

Xanthelasmas             Only treat if causing significant     Removal of benign lesions not
                         pain, recurrent infection,            commissioned in secondary care
                         recurrent bleeding or are facially    unless facially disfiguring
                         disfiguring
Viral warts              Not routinely funded                  Treat in primary care only, typically
                                                               with topical salicylic acid.

The removal of any clinically benign skin lesions in primary or secondary care outside these
criteria is only funded on an exceptional funding basis and referrers must obtain prior
approval from the PCT before proceeding to refer such patients for treatment.

The PCT does not commission the referral to secondary care of asymptomatic, benign
dermatological lesions unless facially disfiguring. Occasionally benign lesions are excised in
secondary care because they have been referred as potentially malignant and where this is
the case the excision will be coded and charged as a diagnostic OP or OP procedure as the
expectation is that diagnosis will have been made in the OP department.

 Any benign lesions which need excision as a day-case or IP procedure must be prior
approved by the PCT.
Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.



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Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2013




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                                                                   Annex 13: Breast Surgery

                               PRIOR APPROVAL IS REQUIRED

                        THIS POLICY RELATES TO ALL PATIENTS



NHS Bath and North East Somerset

Policy Statement: Breast Surgery

Date of Issue: September 2010

Criteria to Access Treatment

Funding through the NHS of aesthetic surgery is seen as low priority but treatment may be
considered in exceptional circumstances. Young women who have yet to have children may
not be funded because of breastfeeding difficulties in the future. The following sets out NHS
B&NES’ conditions for exceptionality:

Functionality indications: physical conditions that would be an indication for treatment are
identified for each procedure.

Psychosocial indications: patients who have disabling psychosocial problems related to an
aesthetic problem and for whom surgery is expected to significantly improve quality of life
and social functioning may be considered for surgery. However, this indication alone is not
seen as proof of exceptionality because:

      There is no tool which would provide an objective assessment in the clinical setting to
       measure the severity of psychosocial dysfunction;
      It is known that severity of aesthetic problem does not relate to the extent of
       psychological distress a person would experience;
      There has been limited research that has looked at improvements in psychosocial
       functioning of those severely affected by self-perception following surgery.

Breast Augmentation
Patients with severe congenital absence or gross asymmetry (a difference of more than 2
cup sizes) may be eligible for funding if there is a related effect on psychological health and
there is reason to believe that surgical intervention will improve this condition. All this
information should be well documented in the application before a decision can be made by
the PCT. Requests for funding must be supported by the patient’s clinician (GP and/ or
consultant) and include at least the patient’s height and weight; impact on physical
health and the current bra cup size(s).

Funding will only be approved where there is a clear indication that breast augmentation
surgery is not for cosmetic purposes and a psychological and/or physiotherapy report may be
required to assist the decision making process.

Breast Implants
Requests for removal and replacement of breast implants are not normally supported unless
.



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                                                                                     Page 29 of 36
Breast Reduction
Breast reduction surgery (including that for gynaecomastia – please see note below) is not
normally funded by NHS B&NES except where:
    The patient is adult and post pubertal
    There are functional problems that are impacting significantly on the person’s quality
       of life that is likely to be corrected or significantly improved by surgery; all other
       appropriate non-surgical treatments must be demonstrated to have failed - as part of
       this, patients must have been wearing a professionally fitted support bra for at least 3
       months which has failed to reduce symptoms; and the opinion of the physiotherapist
       or managing consultant has been sought;
    There is a BMI of no more than 27

Gynaecomastia
A man with gynaecomastia must be fully investigated including screening for
endocrinological and drug related causes before surgery is considered. Surgery may be
approved if the patient is:
      Post pubertal
      of normal BMI (<= 25 Kg/m2)
      endocrinological, drug related or other causes have been fully investigated

Breast Mastoplexy (breast lifting)
This treatment will not normally be funded. Exceptions would only be considered if
significant medical or functional problems are resulting, such as severe ulceration.

Corrective Surgery on Nipple
Permanently inverted nipples can usually be treated by means of relatively inexpensive, non-
surgical devices (such as breast shells). Exceptions will only be considered if the condition is
both unresponsive and is causing long-term skin or hygiene problems.

Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.


Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2013




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                                                                           Annex 14: Botox



                             EXCEPTIONAL FUNDING REQUIRED

                          THIS POLICY RELATES TO ALL PATIENTS




NHS Bath and North East Somerset


Policy Statement: Botulinum Toxin for Hyperhidrosis

Date of Issue: June 2011


Botulinum Toxin (Botox) treatment for hyperhidrosis is regarded as a procedure of low
clinical priority.

This procedure is not routinely funded by the PCT.

Instead of Botox, where the patient is suffering from hyperhidirosis which causes functional
impairment and prevents the individual from fulfilling work/study/carer or domestic
responsibilities, the patient should be treated conservatively as follows:

          Recommend the use of aluminium chloride 20% antiperspirants, e.g. Driclor,
           Anhydrol Forte, Odaban Spray, at night just before sleep
          Give advice about lifestyle measures and sources of information and support
          Consider treating any underlying anxiety which may be an exacerbating factor,
           e.g. referral for CBT


Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist.
Evidence of efficacy for hyperhidrosis / excessive sweating is not in itself considered
exceptional.
This condition is often associated with the onset of puberty and this will be taken into account
when reviewing applications from patients under 25 years of age.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Personal
applications from patients cannot be considered.

Approved by (committee)      PEC
Date Approved:               February 2011
Produced by (Title);         Associate Director of Planned Care
Review Date:                 February 2014




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                                                                   Annex 15: Laser Surgery


                        TREATMENT REQUIRES PRIOR APPROVAL

                         THIS POLICY RELATES TO ALL PATIENTS


NHS Bath and North East Somerset


Policy Statement: Laser Surgery

Date of Issue: September 2010

Laser treatment is considered a low clinical priority and access is based on the criteria below.

Will treat:

    Condition                                     Comments
    Haemangioma                                   Prior approval required
    Port wine stains/non-malignant lesions        Prior approval required
    that are on the face of those that are
    large and subsequently disfiguring
    Hair removal if clinically symptomatic /      Only facial hair, and only if disfiguring
    significantly disfiguring                     and causing psychological distress

    A condition that is judged to be clinically   Trust may approve
    suspicious or symptomatic
    Resurfacing                                   Only if undertaken as an alternative to
                                                  dermabrasion

Exclusions:

    Condition                                     Comments
    Dermatological excision of clinical benign    Will not treat as NHS
    asymptomatic skin lesions
    Inflammatory acne vulgaris                    Will not treat as NHS
    Rosacea                                       Will treat if the area is large and the
                                                  erythema severe
    Scars                                         Will not treat as NHS
    Seborrhoeic keratoses                         Will not treat as NHS
    Short sight                                   Will not treat as NHS
    Spider naevi                                  Will not treat as NHS
    Tattoo removal                                Will not treat as NHS
    Telangiectasia                                Will not treat as NHS unless due to
                                                  radiotherapy and conspicuous
    Thread veins/Venous flares                    Will not treat as NHS
    Warts                                         Will not treat as NHS




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Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2012




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                                                                   Annex 16: Circumcision


                 HOSPITAL TO APPROVE IF PATIENT MEETS CRITERIA

                        THIS POLICY RELATES TO ALL PATIENTS


NHS Bath and North East Somerset


Policy Statement: Circumcision


Date of Issue: September 2010

Male Circumcision for personal, social, cultural and religious reasons is considered a
procedure of low clinical priority. This procedure is therefore not routinely funded by the
PCT.

Criteria to access treatment

Male Circumcision

Male circumcision will only be provided by the NHS for patients for medical conditions.

Male circumcision will not be routinely funded for personal, social, cultural and religious
reasons.

Female Circumcision

Female circumcision or female genital mutilation is prohibited by the law The Prohibition of
Female Circumcision Act 1995 and will therefore not be funded by the PCT.


Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the Patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:                 August 2010
Produced by (Title);           Associate Director of Planned Care
Review Date:                   August 2013




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                                                              Annex 17: Septorhinoplasty


                       TREATMENT REQUIRES PRIOR APPROVAL

                        THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset


Policy Statement: Septorhinoplasty

Date of Issue: July 2011


Septorhinoplasty is regarded as a procedure of low clinical priority and is not routinely funded
by the PCT.
Septorhinoplasty is funded on a restricted basis only and prior approval must be sought.
Requests will be considered:

         for patients with cleft lip and palate/complex congenital abnormality
         for patients who have continuous nasal airway obstruction that results in significant
          functional impairment/is impacting on health
         significant post-traumatic reconstruction where the injury has caused significant
          functional impairment/is impacting on the patient’s health

Requests will not be considered for cosmetic reasons.


Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:
Produced by (Title);           Associate Director of Planned Care
Review Date:                   June 2016




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                                                               Annex 18: Needle phobia



                       TREATMENT REQUIRES PRIOR APPROVAL

                        THIS POLICY RELATES TO ALL PATIENTS

NHS Bath and North East Somerset
Policy Statement: Treatment under general anaesthetic for procedures routinely
provided under local anaesthetic

Date of Issue: July 2011

Services that are routinely provided under local anaesthetic (e.g. vasectomy, lesion removal)
are not commissioned under general anaesthetic and prior approval must be sought.

Where patients are severely needle phobic referrers should consider:

         advice and guidance, including counselling
         use of topical local anaesthetics
         anti-anxiety medication


Note: Patients who are not eligible for treatment under this policy may be considered on an
individual basis where their GP or consultant believes exceptional circumstances exist, that
warrant deviation from the rule of this policy.

Individual cases will be reviewed at the PCT Exceptional Funding Panel upon receipt of a
completed application form from the patient’s GP, Consultant or Clinician. Applications can
not be considered from patients personally.

Approved by (committee)        PEC
Date Approved:
Produced by (Title);           Associate Director of Planned Care
Review Date:                   June 2016




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