Policy for Leicester Leicestershire and Rutland Approved Referral Pathways

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Reference number: ARP 1 Title: Policy for Leicester Leicestershire and Rutland Approved Referral Pathways Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

The clinical commissioning groups in Leicester, Leicestershire and Rutland work together in partnership with the other health and social care organisations locally to plan health services. This partnership is known as Better Care Together. You can read more about the work of the partnership by visiting www.bettercareleicester.nhs.uk

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Policy for Leicester Leicestershire and Rutland Approved Referral Pathways

1.0 INTRODUCTION The purpose of this policy is to describe the clinical threshold and exclusion criteria which the Leicester, Leicestershire and Rutland (LLR) Clinical Commissioning Groups (CCG) listed below, have agreed to for planned procedures and treatments contained within this policy.

Please note that all red flag concerns and 2 WW pathways are excluded from this document. This document brings together the

• East Midlands Cosmetic Policy (2014) • Right Care 4th Wave (2016) • Reversal of Sterilisation and Reversal of Vasectomy (2010) • Male Circumcision (2010) • Sleep Study Referral Process (2015) • Screening for Obstructive Sleep Apnoea (2014) • Adult Management of Snoring (2015)

Many of the procedures and treatments included in this document have been previously been referred to as Procedures of Low Clinical Value. This is not to say that the activity is not of value but only in the right clinical circumstance. To avoid any misinterpretation LLR CCGs have taken feedback from clinical staff and renamed this document Approved Referral Pathways.

1.1 BACKGROUND

This policy document has been agreed to and is supported by • East Leicestershire and Rutland CCG • Leicester City CCG • West Leicestershire CCG

The policy aims to improve consistency of access so allowing fair and equitable planned treatment for the population of LLR. It ensures that

• Patients receive appropriate health treatments in the right place and at the right time • Treatments with no or a very limited clinical evidence base are not used

CCG are responsible for commissioning healthcare services that meet the reasonable requirements of their population. This is done within an agreed financial envelope. This policy enables CCG to prioritise their resources using the best evidence about what is clinically effective and to provide the greatest proven health gain.

1.2 PRINCIPLES The agreed parameters have been made in consultation with primary and secondary care clinicians, public health and patient representatives, in accordance to the principles set out below Full policy title – version number, draft Page 3 of 7 • Clear evidence of clinical effectiveness • Clear evidence of cost effectiveness • The cost of treatment to the patient has been taken in to account • The extent to which individuals or patient groups will benefit from the treatment • Balance the needs of the individual against the benefit which could be gained by alternative investment possibilities to meet the needs of the community • Consider all relevant national standards an authoritative guidance • Where treatment is supported, it is delivered in the most appropriate clinical setting based on clinical need

1.3 SCOPE This policy covers planned procedures and treatments that LLR CCGs will either not fund or will fund when the patient reaches a specified clinical threshold. These thresholds have been agreed to in consultation with clinicians from University Hospitals Leicester (UHL) and CCG clinical leads. The policies are categorised as either • Not routinely funded • Threshold Criteria

1.4 NOT ROUTINELY FUNDED TREATMENT OR PROCEDURE This is a group of treatments or procedures that the CCGs do not fund as not having the treatment or procedure will not have a negative impact on the patient’s physical or mental wellbeing.

However LLR CCGs will fund these treatments/ procedures in the following circumstances • Post- trauma • Part of a reconstruction following surgery e.g. for cancer • Part of the management of a congenital abnormality which results in a serious health function deficit • For a condition directly attributable to a previous medical treatment delivered within the NHS. This excludes known side effects of a treatment or possible complications which the patient would normally be notified of as part of the benefits and risks of the consenting processes • CCGs will fund the treatment if an Individual Funding Request (IFR) application proves there to be an exceptional clinical need, which is also supported by the CCG

1.5 THRESHOLD CRITERIA FOR TREATMENT OR PROCEDURE

This means LLR CCGs will only fund if the patient meets the stated clinical threshold for treatment.

1.6 INDIVIDUAL FUNDING REQUEST (IFR)

There may be times where there it is clinically appropriate to fund a procedure which is NOT ROUTINELY FUNDED. LLR CCG will consider these requests on a case by case basis by application to the IFR panel. Please refer to the INDIVIDUAL FUNDING REQUEST (IFR) PRISM pathway for forms and guidance The panel will focus on the following

Full policy title – version number, draft Page 4 of 7 • Are there any clinical features of the patient’s case which make the patient significantly different to the general population of patients with the condition in question at the same stage of progression of the condition? • Would the patient be likely to gain significantly more benefit from the requested intervention than might normally expected for the general population of patients with the condition at the same stage of the progression of the condition? This process is currently under review and any agreed changes will be reflected in this policy

1.7 PRIOR APPROVAL

PRIOR APPROVAL is another check point to ensure the patient meets the threshold criteria. This process is managed by a third party, who may ask for further information and compare the referral against the criteria of the policy.

All funding request for female and male breast surgery and abdominoplasty, need to be referred to the Cosmetic Surgery Request Officer for PRIOR APPROVAL. Photographs are required. The Cosmetic Surgery Request Officer will advise attendance at either UHL Medical Photography or Body Aspects. Funding decisions will be based on an assessment of the referral against the eligibility criteria described in this policy. All required information must accompany the referral and sent to [email protected] The Cosmetic Surgery Request Officer will check the paperwork for completion and ensure that BMI and smoking criteria are met and refer the patient for 3D body scan or photographs as required. A panel comprising of a Public Health Consultation, GP and Plastic Surgery Consultant meet bi monthly to review referrals with supporting evidence. The GP and patient will be notified in writing of the outcome of funding request. Providers must ensure that PRIOR APPROVAL has been given before commencing any treatment pathway For further information contact: Cosmetic Surgery Request Officer 0116 295 3437 or email: [email protected] Currently CCGs are piloting using PRIOR APPROVAL to support the Benign Skin Lesion policy. In the future the CCGs may extend the use of this checking mechanism.

1.8 EQUALITY AND QUALITY IMPACT ASSESSMENTS

The LLR CCGs have worked in collaboration with the Equality and Inclusion Business Partner (Midland and Lancashire Clinical Support Unit) and the Lead Nurse for Clinical Governance, LCCCG to assess the to assess the impact of the policies on the population of LLR.

1.9 CONSULTATION PROCESS

The following table lists the LLR clinicians who have been involved in the development of this policy.

Name Organisation Ms Armstrong UHL, Orthopaedic Surgeon Mr Banerjee UHL, ENT Surgeon Ms Barney UHL, Gynaecologist Dr Bashab GPSI, Vasectomy

Full policy title – version number, draft Page 5 of 7 Ms Bowen UHL, General Surgeon Mr Brown UHL, Orthopaedic Surgeon Dr Burd UHL, Dermatologist Ms Busby- Earle UHL, Maxillofacial Surgeon Ms Carter UHL, Pharmacist Dr Chidlow Director Alliance, GPSI Dr Daniel Leicestershire County Council and ELRCCG, Public Health Ms Elroy UHL, ENT Surgeon Dr Fox ELRCCG, GP Lead Dr Ghaly GPSI Mr Goddard UHL, Urologist Mr Godsiff UHL, Orthopaedic Surgeon Dr Grant UHL, Clinical Director of Alliance LLR NHS Partners and Head of Service for Gastroenterology Dr Johnson ELRCCG, GP Lead Prof Kockelbergh UHL, Urologist Mr Kulkarni UHL, Orthopaedic Surgeon Dr Marshall UHL, Deputy Medical Director Mr Metcalfe UHL, Deputy Medical Director Ms Matthews UHL, Midwife Dr McHugh Leicestershire County Council and WLCCG, Public Health Dr Miri GPSI Dr Mosaku UHL, Orthodontist Dr Nainani LCCCG, GP Lead Ms Yii UHL, Plastic Surgeon Mr Omar UHL, Orthopaedic Surgeon Mr Pandey UHL, Orthopaedic Surgeon Dr Pulman GPSI Dr Ramnani UHL, Neurologist Dr Roy LCCCG, GP Lead Dr Sampath UHL, Ophthalmologist Dr Shah WLCCG, GP Lead Dr Simpson UHL, Neurologist Mr Stewart UHL, Medicine Mr Summerton UHL, Urologist Mr Sutton UHL, General Surgeon Mr Teo UHL, Gynaecologist Dr Trzcinski WLCCG, GP Lead Dr Vasu UHL, Pain Management Specialist Dr Wiesender UHL, Obstetrician

1.9.1 PUBLIC ENGAGEMENT

LLR undertook a six week period of public and clinician engagement. A number of methods were used to gather feedback including public events in each of the CCGs, on line surveys, visiting specific clinics and asking patients attending their views. Information was sent to a number of patient groups offering face to face meetings to discuss. Information was also posted out to anyone requesting it.

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1.10 IMPLEMENTATION

Commissioners, GPs, service providers and clinical staff treating patients registered with a LLR GP are expected to implement this policy. When the procedures/ treatments are undertaken on the basis of meeting threshold criteria this should be clearly documented within the patient’s clinical notes and referral. A number of PRISM pathways have been developed to assist referrers in making appropriate referrals that meet the required criteria.

Where there is uncertainty regarding threshold criteria, the referring GP can use Advice and Guidance via ERS to determine whether a referral is required or not.

1.11 MONITORING AND REVIEW

This policy will be subject to continued monitoring using a mix of the following approaches

• Prior approval process • Individual funding requests • Post activity monitoring through routine data • Post activity monitoring through clinical audit

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Abdominal Hernias in Adults – Management of

Reference number: ARP 2 Title: Policy for Abdominal Hernias in Adults – Management of Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Management of Abdominal Hernias in Adults

Category Threshold Criteria

A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall.

This policy covers the management of abdominal hernias including inguinal, femoral, umbilical, and incisional hernias, with criteria for referrals/treatment. The term ‘ventral hernia’ is a nonspecific term which could include umbilical, epigastric or incisional hernias, and therefore the more specific term must be used.

Eligibility

LLR CCGs will fund the treatment of abdominal hernias in the following circumstances • Hernias in female patients All suspected groin hernias in females should be referred to secondary care due to the increased risk of incarceration/strangulation. • Inguinal hernias: Surgical treatment for asymptomatic or mildly symptomatic inguinal hernias in adults are NOT ROUTINLY FUNDED When symptoms are mild, the risk of complication is low. There is evidence that it is safe to manage asymptomatic inguinal hernias non operatively – watchful waiting. Garments such as hernia pants can provide support for patients with a hernia Patients should be referred if the meet the following criteria

o There is an inguinal –scrotal hernia o It increases in size month to month o Pain or discomfort significantly interferes with daily activities o History of incarceration or real difficulty in reducing the hernia

• Femoral hernias: All suspected femoral hernias should be referred to secondary care due to the increased risk of incarceration/strangulation • Umbilical, Para-umbilical: Umbilical hernias appear as a painless lump in or near the navel. The majority will resolve by themselves. Umbilical hernias in children under 2 years of age will not be operated on until the third year

Full policy title – version number, draft Page 3 of 4 of life. Indication for operative repair include

o Pain o Incarceration o Strangulation o Defect larger than 1cm o Skin ulceration o Hernia rupture

• Epigastric hernias Epigastric hernias need to be clearly differentiated from divarication of the recti, which is a widening of the linea alba without a defect in the fascia. Patients should be referred if they meet the following criteria

o Hernia increasing in size o Abdominal pain o Nausea and vomiting

• Incisional hernia Asymptomatic incisional hernias do not need to be operated on

Guidance http://www.coventryrugbygpgateway.nhs.uk/pages/umbilical-hernia/ http://www.enhertsccg.nhs.uk/sites/default/files/documents/Jun2017/Guidance%2025%20- %20Management%20of%20abdominal%20hernias%20in%20adults_0.pdf https://www.ncbi.nlm.nih.gov/books/NBK395550/

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Abdominoplasty/ Apronectomy

Reference number: ARP 3 Title: Policy for Abdominoplasty/ Apronectomy Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Abdominoplasty/ Apronectomy

Category Threshold Criteria

An abdominoplasty is cosmetic surgery to improve the shape of the tummy area (abdomen). It can involve removing fat and excess loose skin and tightening the abdominal muscles. The aim is to remove excess tummy skin that can't be removed through exercise. An apronectomy is a modified (abdominoplasty).

Eligibility

All criteria must be met: • Sexual maturation has been reached • Has not already had an abdominoplasty/apronectomy • BMI is between 18 and 25 and has been within this range for 1 year • Confirmed non-smoker and documented abstinence prior to procedure • Photographic evidence • Functionally disabling resulting in severe restrictions in the activities of daily living

This procedure requires PRIOR APPROVAL refer to “The Commissioner – Cosmetic Procedures/ Plastic Surgery CAS” on ERS. And sent to Cosmetic Surgery Request Officer – [email protected]

• Details of condition

• BMI and period maintained

• Smoking status

• Clinical evidence of functionally disabling resulting in severe restrictions in activities of daily living

• Clinical photos

The Cosmetic Surgery Request Officer will acknowledge receipt of the application to the GP and patient as well as the outcome.

If approved the information will be forwarded to the Plastic Surgery department and an assessment appointment made.

If not approved, the GP should discuss the outcome with the patient and alternative options

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Request of Medical Photographs

The patient should be given the Request for Medical Photographs form and asked to attend Medical Illustration at Leicester Royal Infirmary. Medical Illustration will notify the Cosmetic Surgery Request Officer as soon as the patient has attended for photographs

The approval for an assessment is not a guarantee of surgery. There may be other factors that would decide whether surgery is the appropriate option for a patient. This will be discussed with the patient at the assessment stage by the Plastic Surgeon

Guidance

East Midlands Cosmetic Policy 2017 https://www.rcseng.ac.uk/surgeons/surgical-standards/working-practices/cosmetic- surgery/documents/cosmetic-surgery-categorisation-and-requirements/at_download/file https://www.rcseng.ac.uk/members/resources/pre-op-eaflets/Cosmetic/Abdominoplasty.pdf/view

https://prism.leicestershire.nhs.uk/HISCore_PathwayShow.aspx?p=555

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Actinic Keratosis

Reference number: ARP 4 Title: Policy for Actinic Keratosis

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman - Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Actinic Keratosis

Category

Actinic keratosis (AK) is a common sun induced scaly or hyperkeratotic lesion which has the potential to become malignant. NICE estimates that over 23% of the UK population aged over 60 years have AK. The risk of AK turning in to a squamous cell carcinoma is very low, the risk increases over time and the more lesions the person has. The presence of 10 AK lesions is associated with a 14% risk of developing a squamous cell carcinoma within 5 year Recent growth, pain, tenderness, bleeding or ulceration are suggestive of transformation in to a squamous cell carcinoma and should be regarded as a red flag.

Eligibility

LLR CCGs will only fund secondary care referral when the following criteria is met

• Concern of squamous cell refer via 2WW dermatology pathway • Failure to respond to treatment in primary care • Immunosuppressed patient, in particular post-transplant patients

No specific treatment is required for superficial, isolated lesions, which are not causing any discomfort. Patients should be given advice about sun avoidance and protection, as well as the signs of skin cancer formation.

If there is diagnostic uncertainty advice can be sort via Advice and Guidance on ERS

Guidance

https://267lv2ve190med3l1mgc3ys8-wpengine.netdna-ssl.com/wp- content/uploads/2015/10/AK_treatment_algorithm.pdf

http://www.pcds.org.uk/clinical-guidance/actinic-keratosis-syn.-solar-keratosis

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Alopecia

Reference number: ARP 5 Title: Policy for Alopecia Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 20121 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Alopecia

Category

Threshold Criteria

Alopecia is the general medical term for hair loss. There are several types of hair loss with different symptoms and causes.

Male and female pattern baldness This is the most common type of baldness which follows a pattern in men of receding hairline, followed by thinning of the hair on the crown and temples, leaving a horseshoe shape around the back and sides of the head. In women hair usually only thins on the top of the head.

In men it is hereditary and is thought to be caused by over sensitive hair follicles, linked to having too much of a certain male hormone.

Female pattern baldness is less well understood, though it tends to be more noticeable in women who have been through the menopause.

Alopecia areata Alopecia areata causes patches of baldness about the size of a large coin. They usually appear on the scalp but can occur anywhere on the body. It can occur at any age, but mostly affects teenagers and young adults.

In most cases of alopecia areata, hair will grow back in a few months. At first, hair may grow back fine and white, but over time it should thicken and regain its normal colour.

Alopecia areata is caused by a problem with the immune system (the body's natural defence against infection and illness). It's more common among people with other autoimmune conditions, such as an overactive thyroid, diabetes or Down’s Syndrome.

Leaving alopecia areata untreated is a legitimate option for many patients as spontaneous remission occur in up to 80% of patients with limited patchy hair loss of short duration (<1 year).

Scarring alopecia Scarring alopecia is usually caused by complications of another condition. In this type of alopecia, the hair follicle is completely destroyed. This means your hair won't grow back. Early intervention can prevent further and permanent hair loss.

Depending on the condition, the skin where the hair has fallen out is likely to be affected in some way.

Conditions which can cause scarring alopecia include: Full policy title – version number, draft Page 3 of 4 • Scleroderma – a condition affecting the body's connective (supporting) tissues, resulting in hard, puffy and itchy skin

• Lichen Planus - an itchy rash affecting many areas of the body • Discoid Lupus – a mild form of lupus affecting the skin, causing scaly marks and hair loss

• Folliculitis Decalvans – a rare form of alopecia that most commonly affects men, causing baldness and scarring of the affected areas

• Frontal Fibrosing Alopecia – a type of alopecia that affects post-menopausal women where the hair follicles are damaged, and the hair falls out and is unable to grow back

Eligibility

LLR CCGs will fund referral to secondary care in the following situations

• Patients with alopecia areata who have had symptoms for more than 6 months

• Patients with scarring alopecia

LLR CCGs will NOT ROUTINELY FUND surgical treatments for alopecia

Guidance

http://www.bad.org.uk/shared/get-file.ashx?id=41&itemtype=document

http://www.bad.org.uk/shared/get-file.ashx?id=1975&itemtype=document

http://bhamcrosscityccg.nhs.uk/about-us/publication/get-involved/consultations/procedures-of- lower-clinical-value-survey/2643-ccg-procedures-of-limited-clincal-value-policy-january-2

http://www.nhs.uk/Conditions/Hair-loss/Pages/Treatment.aspx

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Arthroscopy of the Knee

Reference number: ARP 6 Title: Policy for Arthroscopy of the Knee Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG(LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Arthroscopy of the Knee

Category

Threshold Criteria

Knee arthroscopy is a technique which allows for the inspection of the interior of the knee. The instrument used is a type of endoscope which is a tube shaped instrument inserted into a cavity in the body to investigate and treat disorders. It is flexible and equipped with lenses and a light source. It is a technically challenging procedure which should only be carried out in specialist units by teams with specific training in the techniques.

Eligibility

LLR CCGs will only fund when one of the following criteria is met: • Knee pain with diagnostic uncertainty following an MRI scan OR • Infection, fracture or avascular necrosis

If MRI does not suggest a surgically curable target then patients will be counselled on their treatment options

Guidance

http://www.shropshireccg.nhs.uk/download.cfm?doc=docm93jijm4n9662.pdf&ver=16858

http://www.enhertsccg.nhs.uk/ccg-guidance-and-policies- final?field_doc_search_words_value=&order=title&sort=desc

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Benign Skin Lesions

Reference number: ARP 7 Title: Policy for Benign Skin Lesions Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body

Date of Approval: ELRCCG LCGGC WLCCG st Date Issued: 1 December 2018

Review Date: November 20121

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Benign Skin Lesions

Category

Threshold Criteria

This policy covers the following benign skin lesions

• Seborrhoeic Warts • Molluscum Contagiosum • Telangiectasia • Spider Angiomas • Skin Tags and Papillomas • Anal skin tags • Acquired Naevi • Benign Haemangiomas • Xanthelasma • Viral Warts

Clinically benign skin lesions should not be removed on purely cosmetic grounds.

Eligibility

LLR CCG will fund treatment if the following is met

• Significant pain • Recurrent infection • Recurrent bleeding • Rapid growth

• Other features suspicious of dysplasia/ malignancy

• Is subject to recurrent trauma leading to bleeding

The referral should include

• Details of condition • Size of lesion/ cyst

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Guidance

East Midlands Cosmetic Policy 2017

http://www.bapras.org.uk/docs/default-source/commissioning-and-policy/information-for- commissioners-of-plastic-surgery-services.pdf?sfvrsn=2

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Botulinum Toxin for Wrinkles, Frown Lines or Ageing Neck

Reference number: ARP 8 Title: Policy for Botulinum Toxin for Wrinkles, Frown Lines or Ageing Neck Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama –SRO Planned Care

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Policy for Botulinum Toxin for Wrinkles, Frown Lines or Ageing Neck

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

• Post trauma • Part of a reconstruction following surgery e.g. for cancer • Part of the management of a congenital abnormality which results in a serious health function deficit • For a condition directly attributable to a previous medical treatment delivered within the NHS. This excludes known side effects of a treatment or possible complications which the patient would normally be notified of as part of the benefits and risks of the consenting process • If exceptional clinical need can be proven via the INDIVIDUAL FUNDING REQUEST application

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

• Are there any clinical features of the patient’s case which make the patient significantly different to the general population of patients with the condition in question at the same stage of progression of the condition?

• Would the patient be likely to gain significantly more benefit from the requested intervention than might normally expected for the general population of patients with the same condition at the same stage of the progression of the condition?

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Botulinum Toxin – The Use of

Reference number: ARP 9 Title: Policy for Botulinum Toxin – The Use of Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Benign Skin Lesions

Category

Threshold Criteria

Botulinum toxin A is a powerful neurotoxin which is used medically to relax muscles and for certain conditions there are recognised clinical benefits to patients. However, due to its mechanism of action botulinum toxin A can be used for medical conditions for which the clinical benefits have not been proven or are unclear and inconsistencies have arisen. Therefore this document summarises the LLR commissioning status of botulinum toxin A for specified medical conditions

The criteria have been decided based upon clinical evidence and clinical expert opinion

Eligibility

LLR CCGs will fund Botulinum Toxin A treatment for the following indications

In all cases specialist input is required to diagnose and prescribe these treatments. Botox® and Xeomin® are formulary choices for the indications stated below. Dysport® should be reserved for use in a) ophthalmology for use in extra ocular muscles

b) patients already on therapy who had previously not responded to Botox® or patients who do not respond to Botox® or Xeomin®

Indication Criteria Choice First Second Choice Choice Achalasia / Patients at high risk (e.g. elderly patients) diffuse of oesophageal perforation from pneumatic Botox* - oesophageal dilation treatment spasm Anal Fissure Third line treatment for patients - unresponsive to GTN 0.4% ointment and Botox* diltiazem ointment

Anismus Unresponsive to other therapies including Botox* - biofeedback therapy

Blepharospasm Botox -

Bladder in line with Botox - Dysfunction NICE CG 171: Urinary incontinence in

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NICE CG 148 Urinary incontinence in neurological disease: Management of lower urinary tract dysfunction in neurological disease. August 2012 Cervical Dystonia Xeomin Botox (spasmodic torticollis) Chronic In line with NICE TA260 (headaches on at Migraine least 15 days per month of which at least 8 Botox N/a days are with migraine) Spasticity – Associated with multiple sclerosis, other traumatic or medical brain injury, hereditary Botox* Xeomin* spasticity paraparesis Hemifacial spasm Botox

Hyperhidrosis In line with criteria stated in local cosmetic of the axillae - policy (Appendix 1) Botox severe

Sialorrhea Botox*

Stroke Upper limb spasticity associated with stroke in adults Xeomin Botox Lower limb spasticity associated with Botox stroke in adults *Unlicensed indication

Please check SPCs (Summary of Product Characteristics) of the specific botulinum toxin preparation for exact licencing details. Botulinum toxin units are not interchangeable from one product to another. Botulinum toxin is a red drug to be prescribed in hospitals only. Please note that Botulinum toxin type A for focal spasticity in children is used within LLR and is commissioned by NHSE

LLR CCGs will NOT ROUTINELY FUND Botulinum Toxin A for the treatment of

• Chronic constipation in children • Gastroparesis (evidence for benefit is poor) • Sphincter of Oddi dysfunction (evidence for benefit is poor) • Indications not listed in the above table

Patients who do not meet the criteria for this policy and who have exceptional circumstances may be considered through the usual Individual Funding Request process

Full policy title – version number, draft Page 4 of 6

MHRA Drug Safety Update Botulinum toxin products: rare but serious risk Products that contain botulinum toxin are associated with the risk of serious adverse reactions due to distant spread of toxin. Recommendations include:

• Only physicians with appropriate experience (including use of the required equipment) should administer products that contain botulinum toxin

• Patients or caregivers should be informed about the risk of spread of toxin, and should be advised to seek immediate medical care if problems with swallowing or speech develop, or if respiratory symptoms arise

• Units of botulinum toxin are not interchangeable from one product to another

• Recommended administration techniques and specific dosing guidance (including the recommendation to use the minimum effective dose and titrate according to individual need) should be followed

Guidance

Summary of Product Characteristics Botox 100units (Allergan) available at www.medicines.org.uk last updated 14/3/2017

Summary of Product Characteristics Xeomin 100units (Merz Pharma) available at www.medicines.org.uk last updated 19/7/2016

MHRA Drug Safety Update October 2007; Vol 1, Issue 3: 10.

Nene / Corby Clinical Commissioning Group Botulinum A Commissioning Policy: May 2014

LLR TAS decisions

Full policy title – version number, draft Page 5 of 6

Guidance

East Midlands Cosmetic Policy 2017

http://www.bapras.org.uk/docs/default-source/commissioning-and-policy/information-for- commissioners-of-plastic-surgery-services.pdf?sfvrsn=2

Full policy title – version number, draft Page 6 of 6

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Botulinum Toxin for Adults with Chronic Migraines

Reference number: ARP 10 Title: Policy for Botulinum Toxin for Adults with Chronic Migraines Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG( ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body) West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 5

Policy for Benign Skin Lesions

Category

Threshold Criteria

Botulinum Toxin A is a powerful neurotoxin which is used medically to relax muscles and for certain conditions. It is recommended as an option for the prophylaxis of headaches in adults with chronic migraines

Eligibility

LLR CCGs will fund this treatment if the following criteria is met • Headaches on at least 15 days per month of which at least 8 are with migraine • 3 prophylactic medication options must have been tried and evidenced in the referral to secondary care. This needs to include

o Drug name o Dose and frequency o Start and stop date and reason for discontinuation • Medication overuse headache has been ruled out • Other causative disorders have been ruled out • Patient keeps a headache diary • 3 prophylactic medication options must have been tried

Retreatment Criteria

For patients who meet the above criteria, funding is approved for a first and follow up injection (2 injections) on each occasion. A first response assessment should be made following the 2nd injection o Percentage reduction in headache days per month after the initial 2 treatments measured over a period of at least a month o Number of headache days/ month measured over 3 consecutive months

Treatment should be stopped in patients whose condition o Is not adequately responding to treatment (defined as less than 30% reduction in headache days per month after 2 treatment cycles)

Full policy title – version number, draft Page 3 of 5 OR

o Has changed to episodic migraine (defined as fewer than 15 headache days per month) for 3 consecutive months

People currently receiving botulinum toxin type A should have the option to continue treatment until they and their clinician consider it appropriate to stop.

Guidance

https://www.nice.org.uk/guidance/ta260

www.wiltshireccg.nhs.uk/wp-content/uploads/2013/12/Botulinum-Toxin-A-Policy-2016.08.23.pdf

Full policy title – version number, draft Page 4 of 5 Guidance

East Midlands Cosmetic Policy 2017

http://www.bapras.org.uk/docs/default-source/commissioning-and-policy/information-for- commissioners-of-plastic-surgery-services.pdf?sfvrsn=2

Full policy title – version number, draft Page 5 of 5

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Breast Asymmetry

Reference number: ARP 11 Title: Policy for Breast Asymmetry Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG( LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body

Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 4

Policy for Breast Asymmetry

Category

Threshold Criteria

Eligibility

LLR CCGs will only fund this treatment if all the below criteria is met

• Developmental failure has resulted in unilateral or bilateral absence of breast/ tissue e.g. Poland Syndrome, Tuberous Breast Deformity OR

• To correct breast asymmetry due to trauma or as the result of surgery e.g. mastectomy or lumpectomy, that results in a significant deformity OR

• Sexual maturation has been reached AND

• BMI is between 18 and 25 and has been within this range for 1 year • AND • Confirmed non-smoker and documented abstinence prior to procedure • AND • Asymmetry equal to, or greater than 30% difference in volume between breasts measured by 3D body scan to assess breast volume

LLR CCGs will only fund this treatment if all the below criteria is met

• Developmental failure has resulted in unilateral or bilateral absence of breast/ tissue e.g. Poland Syndrome, Tuberous Breast Deformity OR

• To correct breast asymmetry due to trauma or as the result of surgery e.g. mastectomy or lumpectomy, that results in a significant deformity OR

• Sexual maturation has been reached AND

This procedure requires PRIOR APPROVAL refer to “The Commissioner – Cosmetic Procedures/ Plastic Surgery CAS” on ERS. And sent to Cosmetic Surgery Request Officer - [email protected]

• Details of condition • BMI and period maintained • Smoking status

The patient will be asked to attend Body Aspects for a scan where the GP confirms the patient meets the BMI criterion. If the BMI is outside of the criterion she will not be scanned. Once patient has been scanned a report will be sent to the Cosmetic Surgery Request Officer

If approved the information will be forwarded to the Plastic Surgery department and an assessment appointment made.

If not approved, the GP should discuss the outcome with the patient and alternative options

Guidance

East Midlands Cosmetic Policy 2017 https://prism.leicestershire.nhs.uk/HISCore_PathwayShow.aspx?p=562

Guidance

East Midlands Cosmetic Policy 2017

http://www.bapras.org.uk/docs/default-source/commissioning-and-policy/information-for- commissioners-of-plastic-surgery-services.pdf?sfvrsn=2

Full policy title – version number, draft Page 4 of 4

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Breast Implant Removal/ Reinsertion

Reference number: ARP 12 Title: Policy for Breast Implant/ Reinsertion Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG(ELRCCG) Governing body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 4

Policy for Breast Implant Removal/ Reinsertion

Category

Threshold Criteria

Eligibility

LLR CCGs will fund the REMOVAL of breast implants for any of the following indications in patients who have undergone cosmetic augmentation mammoplasty that was performed either in the NHS or privately: • Breast disease • Implants complicated by recurrent infections • Implants with capsule formation that is associated with severe pain • Implants with capsule formation that interferes with mammography • Intra or extra capsular rupture of silicone gel-filled implants LLR CCGs will fund insertion of replacement implants in the following circumstance For women whose breast implants are removed in strict compliance with the criteria above AND whose original surgery was funded by the NHS LLR CCGs will NOT ROUTINELY FUND the insertion of replacement implants where the original surgery was funded privately. LLR CCG will NOT ROUTINELY FUND or part fund procedures undertaken in the private sector, irrespective of whether part of that procedure involves removal of a breast implant.

Full policy title – version number, draft Page 3 of 4 This procedure requires PRIOR APPROVAL – refer to “The Commissioner – Cosmetic Procedures/Plastic Surgery CAS” on ERS. And send to the Cosmetic Surgery Request Officer - [email protected] • Details of Condition • Responsibility for implant operation • Smoking Status Referrals for the removal of breast implants where a patient shows any of the above indications but does not meet the criteria for replacement, should be made directly to the Plastic Surgery Department and include: • Patient’s relevant medical history • Which indication the referral is made under

Guidance

East Midlands Cosmetic Policy 2017

Full policy title – version number, draft Page 4 of 4

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Breast Reduction

Reference number: ARP 13 Title: Policy for Breast Reduction

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman –Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 4

Policy for Breast Reduction

Category

Threshold Criteria

Eligibility

LLR CCGs will fund this procedure if all criteria is met

• Sexual maturation has been reached AND

• BMI is between 18 and 25 and has been within this range for 1 year AND

• Confirmed non-smoker and documented abstinence prior to procedure AND

• Breast size is equal to or greater than 1000cc in each breast AND

• Ration of combined breast volume to adjusted partial torso volume is equal to or greater than 13% as measured by 3D Body scan to assess breast volume

*Young woman with juvenile macromastia (juvenile gigantomastia) can be treated prior to reaching sexual maturation

This procedure requires PRIOR APPROVAL refer to “The Commissioner – Cosmetic Procedures/ Plastic Surgery CAS” on ERS. And sent to Cosmetic Surgery Request Officer - [email protected]

• Details of condition • BMI and period maintained • Smoking status

Referral should be made on the Female Breast Surgery Request Application form. The Cosmetic Surgery Request Officer will acknowledge receipt of the application to the GP and patient as well as the outcome. The patient will be asked to attend Body Aspects for a scan where the GP confirms the patient meets the BMI criterion. If the BMI is outside of the criterion she will not be scanned. Once patient has been scanned a report will be sent to the Cosmetic Surgery Request Officer If approved the information will be forwarded to the Plastic Surgery department and an assessment appointment made. If not approved, the GP should discuss the outcome with the patient and alternative options

Full policy title – version number, draft Page 3 of 4

Guidance

East Midlands Cosmetic Policy 2017

Full policy title – version number, draft Page 4 of 4

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Breast Uplift (Mastopexy)

Reference number: ?ARP 14 Title: Policy for Breast Uplift (Mastopexy) Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body

Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 3

Policy for Breast Uplift (Mastopexy)

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Brow Lift (Blepharoplasty)

Reference number: ARP 15 Title: Policy for Brow Lift (Blepharoplasty) Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 3

Policy for Brow Lift (Blepharoplasty)

Category

Threshold Criteria

Blepharoplasty is the plastic surgery operation for correcting defects, deformities and disfigurations of the eyelids and aesthetically modifying the eye region of the face.

Eligibility

LLR CCGs will fund this procedure if one or more of the following criteria is met

• Excess tissue or drooping of the brow/ upper eyelid causing functional visual impairment OR • To repair defects predisposing to corneal or conjunctival irritation OR • Entropion or ectropion OR • Periorbital sequelae of thyroid or nerve palsy or trauma OR • Prosthesis problems in an anophthalmia socket OR • Painful symptoms of blepharospam OR • Significant defect – 40 degrees above the midline, confirmed by Visual Field Test

Guidance

East Midlands Cosmetic Policy 2017 http://www.shropshireccg.nhs.uk/download.cfm?doc=docm93jijm4n9662.pdf&ver=16858

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Bunions (Hallux Valgus)

Reference number: ARP 16

Title: Policy for Bunions (Hallux Valgus)

Version number: 1

East Leicestershire and Rutland CCG (ELRCCG) Policy Approved by: Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Ket Chudasama – SRO Planned Care Director:

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 4

Policy for Bunions (Hallux Valgus)

Category

Threshold Criteria

Hallux valgus, commonly known as bunions, can cause varying degree of pain with limitation of function and mobility as an effect of pressure from shoes over the medial prominence of the metatarsal head. Conservative management such as orthoses does not always help to recover from symptoms and improve the long-term outcome. Surgical intervention can bring significant improvements in symptoms and clinical parameters, but is not always without a risk.

In the first instance, conservative management techniques should be employed. These techniques include: • Avoiding high heel shoes and wearing wide fitting leather shoes which stretch • Non-surgical treatments such as bunion pads, splints, insoles or shields. • Simple analgesia.

CCGs will NOT ROUTINELY FUND surgery for asymptomatic bunions for cosmetic purposes

Surgical treatment of bunions is a community hospital service.

Eligibility

LLR CCGs will only fund this procedure if the following criteria is met

• Conservative management has failed

AND

• The patient suffers from severe pain or deformity that causes significant functional impairment, including:

o Symptoms which prevent the patient fulfilling work or educational responsibilities

o Symptoms which prevent the patient carrying out domestic or carer activities

Full policy title – version number, draft Page 3 of 4 Guidance

http://www.enhertsccg.nhs.uk/ccg-guidance-and-policies- final?field_doc_search_words_value=&order=title&sort=desc http://www.shropshireccg.nhs.uk/download.cfm?doc=docm93jijm4n9662.pdf&ver=16858

Full policy title – version number, draft Page 4 of 4

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Calf Augmentation

Reference number: ARP 17 Title: Policy for Calf Augmentation

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

1st December 2018 Date Issued: November 2021 Review Date: Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 3

Policy for Calf Augmentation

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Carpal Tunnel Syndrome

Reference number: ARP 18 Title: Policy for Carpal Tunnel Syndrome Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 4

Policy for Carpal Tunnel Syndrome

Category

Threshold Criteria

Carpal tunnel syndrome (CTS) is a common condition that causes a tingling sensation, numbness, and sometimes pain in the hand and fingers.

These sensations usually develop gradually and start off being worse during the night. They tend to affect the thumb, index finger and middle finger.

The Carpal Tunnel procedure should be performed in a Primary Care Service and only patients who are not clinically appropriate should be referred to secondary care services.

Patients should be referred urgently if there is evidence of neurological deficit or median nerve denervation e.g. sensory blunting, muscle wasting or weakness of thenar abduction

Eligibility

LLR CCGs will fund this referral if the following criteria is met

• Patients with mild to moderate presentation have recurrent symptoms for more than 6 months and have had conservative therapies i.e. local corticosteroid injection and/ or nocturnal splinting AND

• After 6 months symptoms persist or deteriorate OR

• Patients with severe symptoms

Electromyography (EMG)

EMG is not required for every person with CTS. The use of a scored questionnaire can replace the need for nerve conduction studies in the initial assessment of patients presenting with CTS (appendix A)

Full policy title – version number, draft Page 3 of 4 The following table defines the severity of presentation

Mild Moderate Severe Intermittent paraesthesia Constant paraesthesia interfering The patient has constant or pain with activities of daily living or numbness or pain, with weakened causing considerable sleep or wasting of the thumb muscles disturbance.

Symptoms may be relieved by clenching or shaking the hand

Guidance

https://www.arthritisresearchuk.org/~/media/Files/Education/.../HO03-June-2004.ashx http://www.bssh.ac.uk/education/guidelines/carpal_tunnel_syndrome.pdf http://www.coventryrugbygpgateway.nhs.uk/pages/carpal-tunnel-syndrome/

J Hand Surg [Br] 29(1):95-6 Kamath and Stothard,”Erratum to: A clinical questionnaire for the diagnosis of carpal tunnel syndrome”. 2004 The British Society of Surgery if the Hand

Right Care – Planned Care- 4th Wave Implementation Strategy 2016

http://sdm.rightcare.nhs.uk/pda/carpal-tunnel-syndrome/introduction/

Full policy title – version number, draft Page 4 of 4

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Cataracts

Reference number: ARP 19

Title: Policy for Cataracts

Version number: 1

East Leicestershire and Rutland CCG (ELRCCG) Policy Approved by: Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 4

Policy for Cataracts

Category

Threshold Criteria

Eligibility

First Eye Second Eye Visual acuity is 6/12 or worse (including with If the first eye does not achieve a VA of 6/9 or correction) in the worst eye where poor visual better, then the second eye should be dealt with on acuity arises from cataracts clinical merit, taking into account any directly related work circumstances In bilateral cataracts – surgery should be offered for the worst effected eye (unless There are circumstances, where despite good contra indicated) acuities there is still a clinical need to operate on the second eye e.g. where there is resultant Patients with better acuity may be offered anisometropia which would result in poor binocular surgery if they meet any of the following vision or even diplopia criteria • Working in an occupation which a good acuity is essential • Patients with posterior subcapsular cataracts and those with cortical cataracts who experience problems with glare and a reduction in acuity in bright conditions • Patients who need to drive who experience significant glare which affects driving • Patients with visual field defects borderline for driving, where cataract extraction would be expected to significantly improve the visual field • Patients with glaucoma who require cataract surgery to control intra ocular pressure • Patients with diabetes who require clear views of their retina to look for retinopathy

Full policy title – version number, draft Page 3 of 4

Guidance

http://bhamcrosscityccg.nhs.uk/about-us/publication/get-involved/consultations/procedures-of- lower-clinical-value-survey/2643-ccg-procedures-of-limited-clincal-value-policy-january-2016/file http://www.enhertsccg.nhs.uk/ccg-guidance-and-policies- final?field_doc_search_words_value=&order=title&sort=desc

Right Care – Planned Care – 4th Wave Implementation Strategy 2016 http://www.shropshireccg.nhs.uk/download.cfm?doc=docm93jijm4n9662.pdf&ver=16858

Full policy title – version number, draft Page 4 of 4

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Chalazion – Excision of

Reference number: ARP 20

Policy for Chalazion – Excision of Title: Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG WLCCG WLCCG Date Issued: 1at December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 3

Policy for Chalazion

Category

Threshold Criteria

Located in the upper and lower eyelids there are small oil producing glands, called meibomian glands. If oil becomes trapped within these glands, they become inflamed and create a cyst (chalazion). A cyst may go away on its own or with warm compresses

People who have a cyst are often prone to getting more in the future, either at the same site or other areas of the eyelids. Treatment is removal of the cyst (chalazion excision) if it persists.

Eligibility

This procedure is not normally funded in secondary care.

LLR CCGs will only fund this procedure when all of the following criteria are met:

• Has been present for more than 3 months verified in clinical notes. AND • Has been managed conservatively with heat, lid cleaning and massage for 4 weeks. AND • Where it is present on the upper eyelid, and interferes significantly with vision. AND • Where it is a source of regular infection that has required medical attention twice or more within a six month time frame.

In common with all types of lesions, the CCG will fund removal where malignancy is suspected.

Guidance

/www.swindonccg.nhs.uk/index.php/about-us/what-we-do-and-don-t-fund/460-chalazion-1/file

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Chin/ Cheek Implants

Reference number: ARP 21 Title: Policy for Chin/ Cheek Implants

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

1st December 2018 Date Issued: November 2021 Review Date: Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 3

Policy for Chin/ Cheek Implants

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Cholecystectomy - Asymptomatic

Reference number: ARP 22 Title: Policy for Cholecystectomy - Asymptomatic Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body

Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 3

Policy for Cholecystectomy - Asymptomatic

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Circumcision – Adult Male

Reference number: ARP 23 Title: Policy for Circumcision – Adult Male Version number: 1 Policy Approved by: East Leicestershire and Rutland (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care

Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 3

Policy for Circumcision – Adult Male

Category

Threshold Criteria

Male circumcision is an operation to remove the foreskin (the skin covering the top of the penis). It is mostly done in babies and young children but can be done at any age. It is an effective procedure and confers benefit for a range of medical indications. Sometimes it is requested on cultural, social and religious reasons and is a common practice in the Jewish and Islamic faiths, and is also practiced by many African communities as a tribal or ethnic tradition.

This policy refers only to male circumcision for medical reasons. Non-medical circumcisions do not confer any health gain but do carry health risk.

Note: Female circumcision has no medical benefits and is illegal under the Female Genital Mutilation Act (2003).

Eligibility

LLR CCGs will fund Circumcision for the following medical circumstances:

• Penile cancer • Pathological phimosis - a condition where the foreskin gets trapped under the tip of the penis • 3 documented episodes of balanoposthitis (inflammation of the head of the penis). This can lead to Phimosis, a condition where the foreskin is too tight to be pulled back over the head of the penis (glans). Both can be indications for circumcision. • Balanitis Xerotica Obliterans, otherwise known as male genital or penile lichen sclerosus. • Relative indications for circumcision or other foreskin surgery include the following: - Prevention of urinary tract infection in patients with an abnormal urinary tract - Recurrent paraphimosis, defined as EITHER repeated episodes managed in primary care OR a single episode requiring an emergency attendance in secondary care. - Trauma (e.g. zipper injury) - Tight foreskin causing pain on arousal/ interfering with sexual function - Congenital abnormalities -

Guidance

http://www.rcseng.ac.uk/surgeons/surgical-standards/docs/foreskin-conditions-draft-commissioning- guidance/at_download/file

http://www.nhs.uk/Conditions/Circumcision/Pages/Introduction.aspx

http://bhamcrosscityccg.nhs.uk/your-health-services/treatment-policies-new/male-circumcision

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Collagen Implant

Reference number: ARP 24 Title: Policy for Collagen Implant Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Collagen Implant

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Complementary and Alternative Therapies

Reference number: ARP 25 Title: Policy for Complementary and Alternative Therapies Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Complementary and Alternative Therapies

Category NRF

This commissioning policy has been produced in order to provide and ensure equity, consistency and clarity in the Clinical Commissioning Group’s approach to complementary and alternative therapies.

The policy reflects the lack of high quality research data available to support the use of these therapies. Complementary and alternative therapies are NOT ROUTINELY FUNDED by the CCG as “stand-alone” treatments due to a paucity of information on clinical effectiveness.

In certain circumstances, some of the procedures are commissioned as part of a broader contract with a mainstream provider (for example specialist pain management, oncology, palliative care and musculoskeletal [MSK] services) in a multi-disciplinary approach to symptom control.

Eligibility

Complementary and alternative therapies are not commissioned by the CCG as stand-alone treatment. The alternative and complimentary therapies and alternative disciplines covered by this policy include: • Acupuncture • Alexander Technique • Anthroposophical medicine • Aromatherapy • Bach and other flower remedies • Chinese herbal medicine • Chiropractic • Crystal therapy • Dowsing • Eastern medicine • Healing Nutritional medicine • Herbal medicine • Hypnotherapy • Iridology • Kinesiology • Maharishi Ayurvedic medicine • Massage • Meditation • Naturopathy • Neutralising Antigens/clinical ecology/environmental medicine • Osteopathy • Pilates • Radionics • Reflexology • Shiatsu • Traditional Chinese medicine • Yoga N.B. The alternative and complimentary therapies / disciplines listed above are not exhaustive.

Guidance

http://www.warwickshirenorthccg.nhs.uk/mf.ashx?ID=4bf6906f-4835-4814-b0f0-87e75f57ad01

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Congenital Pigmented Lesion on the Face

Reference number: ARP 26 Title: Policy for Congenital Pigmented Lesion on the Face Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Congenital Pigmented Lesion on the Face

Category

Threshold Criteria

Pigmented skin lesions are patches on the skin which can appear black, brown or blue. These patches are the result of activity involving melanin or blood. These pigments can be either benign in nature, or they can be malignant.

Any lesions where there is concern about malignancy should be referred using the 2WW pathway

Eligibility

LLR CCGs will fund treatment of congenital pigmented lesions on the FACE only, if all of the following criteria is met

• The patient is aged less than 18 year at the time of referral AND

• The child (not just the parent/ carer) expresses concern AND

• The lesion is located on the face AND

• The lesion is at least 1cm in size

The referral should include • Details of condition • Size of lesion • Age of child • Evidence of function / trauma

Guidance

East Midlands Cosmetic Policy 2017

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Correction of Nipple Inversion

Reference number: ARP 27 Title: Policy for Correction of Nipple Inversion Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Correction of Nipple Inversion

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Cranial Banding for Positional Plagiocephaly

Reference number: ARP 28 Title: Policy for Cranial Banding for Positional Plagiocephaly Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Cranial Banding for Positional Plagiocephaly

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Cryopreservation – Gamete/ Embryo

Reference number: ARP 29 Title: Policy for Cryopreservation – Gamete/ Embryo Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Cryopreservation – Gamete/ Embryo

Category

Threshold Criteria

Cryopreservation is a technique that freezes an individual’s egg or sperm for use in future fertility treatment. Cryopreservation of sperm is a well- established technique used to maintain an individual’s fertility. Cryopreservation of eggs is a newer technology, though has been widely used in relation to cancer treatment for a number of years.

Eligibility

LLR CCGs will funded gamete/ embryo cryopreservation if the patients is about to commence treatment that may cause permanent infertility • Malignancies requiring chemotherapy • Malignancies requiring body irradiation or radiotherapy that may affect an individual’s reproductive organs • Conditions requiring male urological or female gynaecological surgery • Other autoimmune conditions requiring the use of chemotherapy e.g. rheumatoid arthritis

Women who are preparing for medical treatment for cancer that is likely to make them infertile, should only be offered oocyte cryopreservation if them meet all of the following criteria • They are well enough to undergo ovarian stimulation and egg collection AND • There is sufficient time available to harvest eggs before the start of their cancer treatment

Women who are undergoing gynaecological surgery should only be offered oocyte cryopreservation if, following surgery, pregnancy would still be viable.

Age Females of reproductive age up to 42 year old (stimulation treatment to take place prior to the 43rd birthday)

There is no age limit for males. Surgical sperm retrieval can be performed in exceptional circumstances.

Referral in to this service should be by the consultant responsible for the care resulting in infertility

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Guidance

Human Fertilisation and Embryo Authority (2009) www.Hfea.gov.uk/46.html

NICE (2004) Clinical Guidance 11: Fertility: assessment and treatment for people with fertility problems

Cutting, R. et al (2009) Human oocyte preservation: Evidence for practice Human Fertility 12(3): 125-136

Royal Collee of Physicians, The Royal College of Radiologists and the Royal College of Obstetricians and Gynaecologists (2007) The effects of cancer treatment on reproductive functions: Guidance on management

Cobo, A. and Diaz, C. (2011) Clinical application of oocyte vitrification: a systematic review and meta- analysis of randomised controlled trials Fertility and Sterility 96(2):277-285

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Dermabrasion and/ or Laser Resurfacing

Reference number: ARP 30 Title: Policy for Dermabrasion and/ or Laser Resurfacing Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Dermabrasion and/ or Laser Resurfacing

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Dupuytren’s Disease

Reference number: ARP 31 Title: Policy for Dupuytren’s Disease

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

1st December 2018 Date Issued: November 2021 Review Date: Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Dupuytren’s Disease

Category

Threshold Criteria

Dupuytren’s disease (Dupuytren's contracture) is a condition that affects the hands and fingers. It causes one or more fingers to bend into the palm of the hand. It can affect one or both hands, and sometimes affect the thumb.

Eligibility

LLR CCGs will fund surgical treatment when

• Conservative and non – operative treatment tried

AND • Patient has loss of extension in one or more joints exceeding 25 degrees OR

• Patient has at least 10 degrees loss of extension in two or more joints

Guidance

http://www.bssh.ac.uk/education/guidelines/dupuytrens_disease.pdf

Right Care – Planned Care – Fourth Wave Implementation Strategy 2016 www.nice.org.uk/guidance/ipg43

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Ear Wax Removal

Reference number: ARP 32 Title: Policy for Ear Wax Removal Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body

Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Ear Wax Removal

Category

Threshold Criteria

Wax is an important and natural secretion found in the ear. It keeps the ear canal lubricated and protects the ear against dust, dirt and bacteria, which helps to prevent infection

Eligibility

LLR CCGs will only fund secondary care treatment where the following criteria is met

• The person has (or is suspected to have) a chronic perforation of the tympanic membrane or healed perforation OR

• There is a past history of ear surgery OR

• There is a foreign body with ear wax (including vegetable matter) in the ear canal OR

• The patient is suffering from significant symptoms due to ear wax build up including hearing loss or pain and the patients’ condition warrants micro suction OR

• Has a recent history of Otalgia and/ or middle ear infection (in the past 6 week) OR

• Has had previous complications following ear irrigation including perforation of the ear drum, severe pain, deafness or vertigo OR

• Two attempts at irrigation of the ear canal in primary care are unsuccessful OR

• Removal of ear wax in patients who have already had ear irrigation in primary care and need complete removal of any residual wax prior to hearing aid fit OR

• Ear canal stenosis OR

• Active skin condition of ear, eczema, psoriasis OR

Full policy title – version number, draft Page 3 of 4 • Recent head injury OR

• Wax in only hearing ear (do not irrigate) OR

• If ear wax is totally occluding the ear canal and any of the following are present o Hearing loss o Earache o Tinnitus o Vertigo o Cough suspected to be due to ear wax o Tympanic membrane is obscured by wax but needs to be viewed to establish a diagnosis o If the person wears a hearing aid, wax is present and an impression needs to be taken of the ear canal for a mould, or if wax is causing the hearing aid to whistle

Guidance

https://www.nice.org.uk/news/article/remove-earwax-if-a-build-up-is-causing-hearing-loss- problems-nice-tells-primary-care http://www.shropshireccg.nhs.uk/download.cfm?doc=docm93jijm4n9662.pdf&ver=16858

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Earlobe Repair

Reference number: ARP 33 Title: Policy for Earlobe Repair Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body

Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Earlobe Repair

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Endo- Vascular Aneurysm Repair

Reference number: ARP 34

Title: Policy for Endo- Vascular Aneurysm Repair

Version number: 1

East Leicestershire and Rutland CCG (ELRCCG) Policy Approved by: Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

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Policy for Endo- Vascular Aneurysm Repair

Category

Threshold Criteria

Endovascular repair is a treatment for abdominal aortic aneurysm (AAA) and an alternative for patients who do not qualify for open surgery. How an AAA is repaired varies depending on location, which then classifies the procedure as either standard (an aneurysm located below the arteries to the kidney) or complex (an aneurysm affecting one or more of the important arteries that branch off the aorta).

Eligibility

LLR CCGs will only funded when all of the following criteria are met Patients are only considered for treatment in the following cases:

• Abdominal aneurysm above 5.5cm unless symptomatic • Thoracic aneurysm above 5.5cm unless symptomatic

Guidance

https://vascular.org/patient-resources/vascular-treatments/endovascular-repair-abdominal-aortic- aneurysms

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Endoscopic Thoracic Sympathectomy for Facial Flushing/ Sweating

Reference number: ARP 35 Title: Policy for Endoscopic Thoracic Sympathectomy for Facial Flushing/ Sweating Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Endoscopic Thoracic Sympathectomy for Facial Flushing/ Sweating

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Endoscopy for Dyspepsia

Reference number: ARP 36 Title: Policy for Endoscopy for Dyspepsia Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Endoscopy for Dyspepsia

Category

Threshold Criteria

Endoscopy is the procedure of choice for the diagnostic evaluation of the UGI tract because of its ease, reliability, diagnostic superiority, and the ability it gives to perform biopsies and/or therapeutic interventions, especially true for patients presenting with dyspepsia.

Eligibility

LLR CCGs will only fund this procedure for patients who have dyspepsia and referred for endoscopy if specific clinical criteria are met.

The aim of the referral criteria is to only select patients who may have significant pathology for endoscopic investigation and to ensure that all patients have appropriate investigation and management in primary care. Referral Process for Dyspepsia Patients who have dyspepsia may only be routinely referred for endoscopy if specific clinical criteria are met. The aim of the referral criteria is to only select patients who may have significant pathology for endoscopic investigation and to ensure that all patients have appropriate investigation and management in primary care. 1. Immediate (same day) Referrals Evidence of significant acute gastrointestinal bleeding. 2. Urgent (two week wait) Referrals • Patients of any age presenting with any of the following alarm symptoms: • Chronic gastrointestinal bleeding • Progressive unintentional weight loss • Progressive difficulty swallowing • Persistent vomiting • Documented iron deficiency anaemia • Epigastric mass • Abnormal barium meal 3. Patients aged 55 years or over with new-onset dyspepsia that is either: • Unexplained i.e. no diagnosis has been made for the dyspepsia or/and

Full policy title – version number, draft Page 3 of 4 Persistent i.e. symptoms for 4-6 weeks but may be shorter depending on severity • Routine Referrals Patients under the age of 55 years, who have no alarm symptoms, will not be routinely offered endoscopy unless specific interventions for un-investigated dyspepsia have first been undertaken in primary care. The following interventions must be undertaken in primary care prior to making a referral for endoscopy and then documented in the GP referral letter. The referral will be assessed by a consultant gastroenterologist and if the GP letter does not contain this information it will be returned by UHL. 4. Primary care interventions for un-investigated dyspepsia: Review of medication for possible causes of dyspepsia e.g. NSAID Suspend treatment and treat with PPI therapy at full dose for at least one month (e.g. Lansoprazole 30mg daily) Empirical treatment with both: • a PPI at full dose for at least one month (e.g. Lansoprazole 30mg daily) and H. Pylori testing and treatment 2 (see notes below). • There is currently inadequate evidence on whether full dose PPI for one month or H. Pylori ‘test and treat’ should be offered first. Either treatment may be tried first and the other then offered if symptoms persist or return. If PPI treatment is tried first, a two-week ‘washout’ period is required before H. Pylori testing. • If symptoms recur after treatment, use PPI therapy at the lowest dose required to control symptoms (possibly on an as-required basis). Recurrence of symptoms is not an indication for referral for endoscopy. If PPI are ineffective at controlling symptoms, treat with H2RA (e.g. Ranitidine 150mg twice a day) and use the lowest dose required to control symptoms (possibly on an as-required basis). Domperidone 10 mg three times a day can be tried when bloating/early satiety or nausea are prominent symptoms. 5. Exceptional Cases. It is recognised that there may be individual clinical circumstances that may warrant an endoscopy but fall outside the guidelines above. In these cases, the GP should provide the relevant additional clinical information in their referral to the gastroenterologist who will then determine whether an endoscopy is clinically necessary.

Guidance

Right Care – Planned Care – Fourth Wave Implementation Strategy 2016

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Epidermoid/ Pillar (Sebaceous) Cyst

Reference number: ARP 37

Title: Policy for Epidermoid/ Pilar (Sebaceous) Cyst

Version number: 1

East Leicestershire and Rutland CCG (ELRCCG) Policy Approved by: Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

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Policy for Epidermoid/ Pilar (Sebaceous) Cyst

Category

Threshold Criteria

Epidermoid and pilar cysts look like small smooth lumps under the surface of the skin. They are generally benign and usually cause no harm or problems. If required, they can usually be removed easily by a small operation done under local anaesthetic. The main reason why some people want them removed is for cosmetic reasons, as they can sometimes look unsightly.

Eligibility

LLR CCGs will fund treatment when one or more of the following criteria is met

• One the face and greater than 1cm in diameter OR

• Greater than 1cm on the body (including scalp and neck) AND associated with significant pain OR loss of function or susceptible to recurrent trauma

Referral should include

• Details of condition • Size of cysts • Evidence of functional/ trauma

Guidance

East Midlands Cosmetic Policy 2017

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Epidural Injections for Radicular Pain (Sciatica)

Reference number: ARP 38 Title: Policy for Epidural Injections for Radicular Pain (Sciatica) Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Epidural Injections for Radicular Pain (Sciatica)

Category

Threshold Criteria

Epidural steroid and/ or anaesthetic injections are a common treatment for relief from many forms of low back pain, leg pain and radicular pain originating from the lumbar, cervical and thoracic region. The epidural injection delivers medication directly to the suspected source of the pain and controls local inflammation that may contribute to the pain.

Pain relief is usually temporary with patients describing the relief for anywhere between 1 month and 1 year.

This treatment is provided as part of a pain management programme by a specialised pain management service

Epidural Injections for patients with chronic non-specific back pain is NOT ROUTINELY FUNDED

The following are excluded from this policy • Children up to the age of 18yrs • Patients with back pain secondary to spinal metastases

Eligibility

The LLR CCGs will fund this treatment when the following criteria is met • The patient is aged 18 years and over AND • All conservative management options have been tried and failed e.g. physiotherapy treatments, guided exercise programmes, pharmacotherapy including analgesia and muscle relaxants AND • Patients experience acute and severe pain (assessed by a pain specialist using a visual analogue Pain Scale or similar)

Do NOT use epidural injections for neurogenic claudication in people who have central spinal canal stenosis

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Guidance

https://www.nice.org.uk/guidance/ng59/resources/low-back-pain-and-sciatica-in-over-16s-assessment- and-management-pdf-1837521693637 https://www.westsuffolkccg.nhs.uk/wp-content/uploads/2014/09/T42-Epidural-Injections-Policy.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Erectile Dysfunction (Impotence)

Reference number: ARP 39

Title: Policy for Erectile Dysfunction (Impotence)

1 Version number: East Leicestershire and Rutland CCG (ELRCCG) Policy Approved by: Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Erectile Dysfunction (Impotence)

Category

Threshold Criteria

Erectile dysfunction (impotence) is defined as an inability to obtain or maintain an erection sufficient for penetration and for the satisfaction of both sexual partners.

Eligibility

LLR CCG will fund treatment as follows

1. Treatment with the phosphodiesterase type -5 inhibitor, generic sildenafil, at the minimum effective dose is recommended for any man presenting with erectile dysfunction with a frequency of dosing for a maximum of four times per month.

2. For all other phosphodiesterase type-5 inhibitors (vardenafil, tadalafil and avanafil) is only recommended for patients who meet the Government Selected List Scheme (SLS) criteria AND where generic sildenafil is ineffective, with a frequency of dosing maximum four times per month using the drug with the lowest acquisition cost.

3. Treatment with prostaglandin E1 intracavernosal injections and intraurethral instillations is only recommended for patients who meet the SLS criteria AND only if oral phosphodiesterase type-5 inhibitors are contraindicated or ineffective. The maximum frequency of dosing should be four times per month using the drug with the lowest acquisition cost.

4. Treatment with Alprostadil cream is not routinely funded due to limited evidence for clinical and cost effectiveness.

5. Treatment with vacuum erection devices may be considered for those men who are intolerant, unable to have Intracavernousal injection therapy (ICI) or oral agents.

6. Treatment with penile implants will be funded for post prostatectomy and complicated acute priapism. Penile implant surgery for end stage erectile dysfunction is NHSE funded.

7. Treatment with psychosexual interventions may be used in the work up with tertiary referral patients

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Guidance

http://www.oxfordshireccg.nhs.uk/professional-resources/documents/commissioning-statements/041e- Erectile-Dysfunction.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Excision of Skin for Cosmetic Indicators

Reference number: ARP 40

Title: Policy for Excision of Skin for Cosmetic

Indicators

Version number: 1

East Leicestershire and Rutland CCG (ELRCCG) Policy Approved by: Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

ELRCCG Date of Approval: LCCCG

WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Ket Chudasama – SRO Planned Care Director:

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Policy for Excision of Skin for Cosmetic Indicators

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Facelift

Reference number: ARP 41 Title: Policy for Facelift Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Facelift

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Facet Joint Injection for Non Radicular Back Pain

Reference number: ARP 42 Title: Policy for Facet Joint Injection for Non Radicular Back Pain Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Facet Joint Injection for Non Radicular Back Pain

Category

Threshold Criteria

Non-radicular (non radiating) back pain is the commonest clinical presentation. Sometimes it is referred to as “mechanical back pain”. It is often the diagnosis for symptoms that are not caused by neural impingement or medically significant other causes.

The standards set by the Spinal Intervention Society and the joint standards of the British Pain Society and the Faculty of Pain Medicine state that • Medial branch block as a diagnostic procedure leading to • Radiofrequency denervation is the medial branch block is positive

Eligibility

LLR CCGs will fund medial branch blocks for the management of cervical, thoracic and lumbar back pain in the following clinical situations

• diagnostic procedure leading to radiofrequency denervation of the medial branch if the diagnostic block is positive AND • all conservative management options have been tried and failed o physiotherapy o exercise o pharmacotherapy including analgesia AND • the pain has resulted in moderate to significant impact on daily life for more than 12 months OR • if the initial medial branch block has had a proven therapeutic benefit but the patient is not suitable for Radiofrequency Denervation or a Pain Management Programme (e.g. multiple comorbidities, cardiac and respiratory dysfunction, cardiac pacemaker or other nerve stimulator, or frail and elderly)

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Guidance

https://www.nice.org.uk/guidance/ng59 http://www.shropshireccg.nhs.uk/media/1119/value-based-commissioning-policies-former-plcv- v30a-june-17.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Facial Hyper Pigmentation – Treatment for

Reference number: ARP 43 Title: Policy for Facial Hyper Pigmentation – Treatment for Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Facial Hyper Pigmentation – Treatment for

Category

Threshold Criteria

Hyperpigmentation results in flat, darkened patches of skin that can vary in size and colour. Pigment spots such as age spots are caused by sun exposure. For this reason, they appear mainly on body parts that are frequently exposed, such as the face, hands and arms

Eligibility

LLR CCGs will support referral to secondary care for Facial Hyperpigmentation, as further investigations as may be necessary, if the following criteria is met • The patient is over 18 years old • The patient is symptomatic

o Burning o Itching o Soreness • Progressive Disease • Atypical/ asymmetric distribution If there is uncertainty about the diagnosis, please seek further advice via Advice and Guidance (using eRS or the PRISM Advice and Guidance pathway)

Guidance

http://www.bad.org.uk/shared/get-file.ashx?id=169&itemtype=document http://www.pcds.org.uk/clinical-guidance/melasma-syn.-chloasma-and-other-causes-of-facial- hyperpigmentation

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Fat Grafts

Reference number: ARP 44 Title: Policy for Fat Grafts Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELCCG) Governing Body Leicester City CCG (LCCCG) Governing body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Fat Grafts

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Fungal Nail Infection (Onychomycosis)

Reference number: ARP 45 Title: Policy for Fungal Nail Infection (Onychmycosis)

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Fungal Nail Infection (Onychomycosis)

Category

Threshold Criteria

Fungal nail infection is a common and often benign condition. Treatment for 12 weeks with drugs only produces a clinical cure, a little over one year after treatment has been completed, in just over half of those treated. There is a risk of relapse and re-infection. Onychomycosis may produce cosmetic symptoms only and it is accepted that in such cases, treatment is not clinically necessary.

Nail clippings should be sent for mycology before treatment is commenced

Where diagnosis is uncertain Advice and Guidance can be used via ERS, which may avoid referral to secondary care.

Eligibility

LLR CCGs will only fund referral to Podiatry where the following criteria is met

• Oral antifungal treatment is required for child under the age of 18 year • The nail is traumatized by the person’s footwear causing pain, or deformed toenails causing pain to adjacent toes • The nail infection is thought to be the source of fungal skin infection • The person has diabetes, vascular disease, or a connective tissue disorder (because of a higher risk for secondary bacterial infections and cellulitis). • The person is, or is likely to become, severely immunocompromised (for example with haematological malignancy or its treatment). • Primary Care treatment is unsuccessful

Guidance

https://cks.nice.org.uk/fungal-nail-infection#!scenario

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Ganglion – Hand or Wrist

Reference number: ARP 46 Title: Policy for Ganglion – Hand or Wrist Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Ganglion – Hand or Wrist

Category

Threshold Criteria

A ganglion is a benign, fluid-filled cyst that forms around joints or tendons. Ganglions can occur alongside any joint, but are most common around the wrist, hands and fingers. Ganglions are harmless and most are symptom free, but they vary in size and can occasionally give pain, weakness, restriction of mobility or pressure neuropathy. Untreated, approximately 50% resolve spontaneously. Recurrence rates after surgery can be up to around 40%. Complications of surgical excision include scar tenderness, joint stiffness and distal numbness.

Surgical excision will not be commissioned for cosmetic reasons

Eligibility

LLR CCGs will only fund this procedure when the following criteria is met

• Significant functional impairment (significant restriction of work/domestic/care duties); significant pain; neurological deficit; weakness of the joint; inhibition of nail growth.

AND

• Awareness of frequency of spontaneous resolution, likelihood of recurrence and possible complications of excision.

Mild/ Moderate Severe Clinical Presentation Dorsal or Palmar wrist swelling Dorsal or Palmar wrist swelling with severe pain or diagnostic uncertainty Management Observe/ Aspiration Refer for surgical assessment

Guidance

http://www.bssh.ac.uk/education/guidelines/ganglion.pdf

Right Care – Planned Care – Fourth Wave Implementation Strategy 2016

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Gastro Fundoplication for Chronic Reflux Oesophagitis

Reference number: ARP 47 Title: Policy for Gastric Fundoplication for Chronic Reflux Oesophagitis Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Gastric Fundoplication for Chronic Reflux Oesophagitis

Category

Threshold Criteria

The procedure is used to tighten the ring of muscle at the bottom of the oesophagus, which helps to stop acid leaking up from the stomach. It's carried out in hospital under general anaesthesia

Eligibility

LLR CCGs will fund this procedure if the following criteria is met

• regular, significant symptoms of gastro-oesophageal reflux despite receiving at least one year of continuous pharmacological treatment up to the maximum dose licensed for reflux oesophagitis OR

• significant volume reflux placing them at risk of aspiration OR

• anaemia because of oesophagitis

Guidance

www.southeasternhampshireccg.nhs.uk/Downloads/Policies/Commissioning%20Policies/Individual%20Fundi ng%20Request%20Policy%20procedure%20CSU%20Com%20004%20V1.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Gender Reassignment – Treatments not included in the original package of care Reference number: ARP 48 Title: Policy for Gender Reassignment – treatments not included in the original package of care

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body

Date of Approval: ELCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Gender Reassignment – Treatments not included in the original package of care

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

• If exceptional clinical need can be proven via the INDIVIDUAL FUNDING REQUEST application

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Gluteal Augmentation

Reference number: ARP 49 Title: Policy for Gluteal Augmentation Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Gluteal Augmentation

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Grommet Insertion – Adults only

Reference number: ARP 50 Title: Policy for Grommet Insertion – Adults only Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Grommet Insertion – Adults only

Category Threshold Criteria

Eligibility

LLR CCGs will fund the insertion of grommets in adults in the following circumstances

Otitis Media with effusion OME that meets the following criteria • Persisting after a prolonged period of watchful waiting / active observation of at least four months (NB watchful waiting is not appropriate if malignancy is suspected. Refer via 2 WW) • There is a definitive diagnosis of OME and • It persists OR • Severe pain due to air pressure changes when flying or in hyperbaric treatment. The serverity and frequency of flying should be discussed with the patient and balanced against the possible complications associated with grommets OR • Reinsertion of ventilation tubes – where it’s been inserted and fallen out – 2nd or 3rd grommet may be inserted if they still meet one of the above criteria

Guidance

www.enhertsccg.nhs.uk/sites/default/files/documents/May2017/Guidance%252072%2520- %2520Grommet%2520Insertions%2520in%2520Adults.pdf+&cd=11&hl=en&ct=clnk&gl=uk

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Hair Depilation for Excessive Growth (Hirsutism)

Reference number: ARP 51 Title: Policy for Hair Depilation for Excessive Growth (Hirsutism) Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Hair Depilation for Excessive Growth (Hirsutism)

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Hair Transplantation

Reference number: ARP 52 Title: Policy for Hair Transplantation Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Hair Transplantation

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Hip and Knee Replacement

Reference number: ARP 53 Title: Policy for Hip and Knee Replacement

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Hip and Knee Replacement

Category

Threshold Criteria

Approximately 160,000 hip and knee replacement procedures are performed annually in England and Wales and there is a national trend towards increasing demand for these. Osteoarthritis is the most common indication for these joint replacement procedures.

Eligibility

LLR CCGs will only funded hip and knee replacement when all of the following criteria are met

Pre Referral Criteria

• Evidence that the management of pre-existing medical conditions has been optimised e.g. anaemic patients have been investigated and treated to bring their Hb within the normal range

AND

• 3 months conservative treatment to include:

o an exercise programme,

o assistive devices e.g. walking aids where indicated

o discussion of weight management and smoking cessation as appropriate

o the use of pharmacological therapy to control symptoms AND

• Confirmation that the patient is willing to undergo surgery

AND

• Evidence that the potential benefits and risks of surgery has been explained using a shared decision making tool

Referral Criteria (based on the classification of pain and functional limitation below)

• Intense or severe symptomology

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• Moderate or severe functional limitations

AND

• Positive clinical examination findings in the specified joint

AND

• X-ray showing any radiological evidence of degenerative disease

Urgent Referral without 3 months conservative treatment

LLR CCGs will only fund when the following criteria is met

• Severe symptomology

OR Severe functional limitation AND

• moderate, intense or server symptomology

Classification of symptomology and functional limitation

SYMPTOMOLOGY Slight Infrequent pain Pain on climbing/ descending stairs Able to perform daily activities except those requiring great physical activity Medication taken to control pain with no/ few side effects Moderate Occasional pain Pain on walking or standing on level surfaces for half an hour Some limitation of daily activities Medication taken to control pain with no /few side effects Intense Almost continuous pain Pain on walking short distances or standing on level surfaces for less than half an hour Significant limitation of daily activities Medication taken continuously to take effect Occasional use of support systems e.g. walking aids Severe Continuous pain Pain at rest Constant significant limitation of daily activities Continuous use of medication with no response or adverse effect Constant use of support systems e.g. walking aid

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FUNCTIONAL LIMITATION Minor Functional capacity adequate to conduct normal activities and self-care Walking capacity of more than one hour No aids needed Moderate Functional capacity adequate to perform only a few or none of the normal activities and self- care Walking capacity of around half an hour Aid e.g. walking stick needed Severe Largely or wholly incapacitated Walking capacity of less than half an hour or unable to walk or bedridden Constant use of aid e.g. walking stick, walker or wheelchair Adapted from: Joint Planned Care Lead for North Kirklees and Wakefield CCG. NHS North Kirklees and Wakefield CCG Commissioning Policy. 2017

The Oxford Scoring Tool is optional and may be used within the clinical consultation to explore the impact on patients, their concerns and to review progression of the condition

Appendix A illustrates the referral criteria.

Guidance http://pathways.nice.org.uk/pathways/osteoarthritis/management-ofosteoarthritis#content=view- node%3Anodes-referral-for-consideration-of-joint-surgery https://pathways.nice.org.uk/pathways/osteoarthritis#path=view%3A/pathways/osteoarthritis/management- of-osteoarthritis.xml&content=view-quality-statement%3Aqualitystatements-referral-for-consideration-of- joint-surgery

Joint Planned Care Lead for North Kirklees and Wakefield CCGs. NHS North Kirklees and Wakefield CCG Commissioning Policy. 2017.

British Orthopaedic Association, Royal College of Surgeons. Commissioning Guide: Pain arising from the Hip in Adults. 2017.

British Orthopaedic Association, Royal College of Surgeons. Commissioning Guide: Painful Osteoarthritis of the Knee. 2017.

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Appendix A

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Hip Arthroscopy

Reference number: ARP 54 Title: Policy for Hip Arthroscopy Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Hip Arthroscopy

Category

Threshold Criteria

Hip arthroscopy is a technique which allows for the inspection of the interior of the hip. The instrument used is a type of endoscope which is a tube shaped instrument inserted into a cavity in the body to investigate and treat disorders. It is flexible and equipped with lenses and a light source. It is a technically challenging procedure which should only be carried out in specialist units by teams with specific training in the techniques.

Eligibility

LLR CCGs will fund this procedure if the following criteria is met Femoro-Acetabular Impingement (FAI) • Diagnosis of definite FAI defined by appropriate investigations – x-ray, MRI and CT scans

• An orthopaedic surgeon who specialises in young adult hip surgery has made the diagnosis. This should include discussion with a specialist musculoskeletal radiologist.

• Severe symptoms typical of FAI with duration of at least 6 months where diagnosis of FAI has been made as above

• Failure to respond to all available conservative treatment options including activity modification, pharmacological intervention and specialist physiotherapy

• Compromised function which requires urgent treatment within 6-8 months’ time frame, or where failure to treat early is likely to significantly compromise surgical options at a future date.

• Treatment with more established surgical procedures is not clinically viable

Sepsis of the hip joint Hip arthroscopy is supported in the washout of an infected hip joint in the following patients:

• Patients who have not responded to medical management

• Patients with underlying disease

• Patients who are immunosuppressed Lose bodies Hip arthroscopy is supported for the removal of radiologically proven loose bodies within the hip

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Excision/ repair of radiological proven labral tear in the absence of osteoarthritis (OA) or femoro- acetabular impingement syndrome: Hip arthroscopy is supported for the excision of radiological proven labral tears associated with an acute traumatic episode in the absence of OA or FAI syndrome

LLR CCGs will not fund hip arthroscopy in patients with femoro- acetabular impingement if any of the following apply:

• Patient has advanced osteo- arthritic change on preoperative x-ray (Tonnis grade 2 or more) or server cartilage injury (Outerbridge grade III or IV) • Patient has a joint space on plain radiograph of the pelvis that is less than 2mm wide anywhere along the sourcil • Patient is a candidate for hip replacement • Patient with severe hip dysplasia or with a Crowe grading classification of 4. • Patient with generalised joint laxity especially in diseases connected with hypermobility of the joints such as Marfins syndrome and Ehlers-Danlos syndrome • Patient with osteogenesis imperfecta

Guidance

http://www.enhertsccg.nhs.uk/sites/default/files/documents/Jun2017/Guidance%2070%20- %20Hip%20Arthroscopy.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Hip Resurfacing

Reference number: ARP 55 Title: Policy for Hip Resurfacing Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Hip Resurfacing

Category

Threshold Criteria

In hip resurfacing, the femoral head is not removed, but is instead trimmed and capped with a smooth metal covering. The damaged bone and cartilage within the socket is removed and replaced with a metal shell, just as in a traditional total hip replacement

Eligibility

LLR CCGs will only fund this procedure if the following criteria is met

• The patient has been assessed by Musculoskeletal Services and diagnosed as suffering from end-stage osteoarthritis suitable for referral for consideration of surgery, AND • The patient has fully engaged with conservative measures for a period of at least six months (clearly detailed throughout the patient’s primary care record or via Musculoskeletal Services’ clinic letters), as detailed within this policy, and this has failed to improve the symptoms of the patient, AND • The patient: o Is suffering from intense or severe persistent pain with moderate or severe functional impairment* when compared to the classification system on the previous page. OR o Has significant instability of the hip joint with significant functional impairment*, OR • Has radiological features of severe disease with moderate functional impairments; OR • Has radiological features of moderate disease with significant functional impairment* or instability of the hip joint and is suffering from. OR • The patient has severe persistent pain that is causing severe functional impairment which is compromising their mobility to such an extent that they are in immediate danger of losing their independence and joint replacement would relieve this, and conservative management as set out in this policy is contra-indicated.

OR • The patient is at risk of destruction of their joint of such severity that delaying surgical correction would increase the technical difficulties of the procedure.

*Significant functional impairment is defined as: - Symptoms preventing the patient fulfilling routine work or educational responsibilities - Symptoms preventing the patient carrying out routine domestic or carer activities

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https://www.bristolccg.nhs.uk/media/medialibrary/2017/10/Knee_Replacement_Surgery_CBA_Policy_v1617. 1.01.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Hybrid Hip Replacement/ Revision

Reference number: ARP 56 Title: Policy for Hybrid Hip Replacement/ Revision Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018

Review Date: November 2021

Document Author: Danah Cadman – Project Manager Planned

Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Hybrid Hip Replacement/ Revision

Category

Threshold Criteria

Eligibility

LLR CCGs will only fund a hybrid hip system in extremely difficult cases. The following criteria must be met

• The patient must meet the clinical criteria for a hip replacement, as detailed in Policy for Hip and Knee Replacement

AND

• There must be evidence of o Loss of Bone o Ligament Insufficiency o Multiple previous hip surgeries.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Hybrid Knee Replacement/ Revision

Reference number: ARP 57 Title: Policy for Hybrid Knee Replacement/ Revision Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Hybrid Knee Replacement/ Revision

Category

Threshold Criteria

This policy also includes the use of Modular Rotating Hinge Knee Systems

Eligibility

LLR CCGs will only fund a hybrid knee system in extremely difficult cases. The following criteria must be met

• The patient must meet the clinical criteria for a knee replacement, as detailed in Policy for Hip and Knee Replacement • AND

• There must be evidence of o Loss of Bone o Ligament Insufficiency o Multiple previous knee surgeries.

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Intraocular Lens Implants

Reference number: ARP 58 Title: Policy for Intraocular Lens Implants Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care

Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

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Policy for Intraocular Lens Implants

Category

Threshold Criteria

Eligibility

LLR CCGs will fund intraocular lens implants as follows

• Lens implants for astigmatism

Standard intraocular lens implants will be provided when patients have surgery, not Toric intraocular lens implants. The standard intraocular lens (IOLs) design used for surgery in the NHS is the monofocal IOLs.

• Toric Intraocular Lenses (IOL) for astigmatism correction in patients undergoing cataract surgery

Will not be routinely funded. This is due to a lack of quality evidence regarding the long term clinical effectiveness of this procedure. There is some evidence to support a case for clinical effectiveness yet the overall quantity of that evidence is such that there is too great a measure of uncertainty over whether the claims made for treatment can be justified.

Guidance

http://www.westnorfolkccg.nhs.uk/sites/default/files/pdf/Agenda%20Item%208.3%20WNCCG%20GB %20Papers%20300715%20Toric%20Intraocular%20Lenses%20for%20corneal%20astigmatism%20 v2%20lcj%20(2).pdf http://www.miltonkeynesccg.nhs.uk/referrals-and-priorities-policies/

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Intrauterine (IUI) and Donor Insemination (DI) (excluding In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI))

Reference number: ARP 59 Title: Policy for Intrauterine (IUI) and Donor Insemination (DI) (excluding In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI)) Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Intrauterine (IUI) and Donor Insemination (DI) (excluding In Vitro Fertilisation (IVF) and Intracytoplasmic Sperm Injection (ICSI))

Category

Threshold Criteria

Infertility is defined, in accordance with the East Midlands Speciality Commission Group Commissioning Policy for IVF and ICSI within Tertiary Infertility Services, as failure to conceive after frequent unprotected sexual intercourse for one to two years in couples in the reproductive age groups or by undertaking 6 cycles of donor insemination without conceiving or by having a defined tubal blockage thereby preventing conception.

Eligibility

All patients are eligible for consultation and advice in primary care.

Patients in the reproductive age group who fail to conceive after frequent unprotected sexual intercourse for one to two years (or by undertaking 6 cycles of Donor Insemination without conceiving or by having a defined tubal blockage thereby preventing conception) should be offered further clinical investigation including semen analysis and assessment of ovulation as appropriate. Where there is clear reproductive pathology, infertility of any duration will be considered. This will include patients who cannot achieve full sexual intercourse due to disability. Eligibility for NHS funded treatment will be assessed against the treatment referral criteria and this may, in turn, affect the decision to investigate Agreed eligibility criteria have been set so that patients with the best chance of success are given priority over others in order to produce the best outcomes. Following referral, patients should have a prognostic estimate that the successful outcome of a cycle will be greater the 10%. Patients who do not meet the criteria within this policy are still entitled to access the primary and secondary care for consultation. Further investigations can be performed if appropriate. Ovulation induction with clomiphene citrate can be accessed within a dedicated secondary or tertiary care unit when clinically appropriate.. Medication should only be prescribed following clinical investigation in line with the NICE Clinical Practice Algorithm, Fertility - Assessment and treatment for people with fertility problems, 2013. In order to achieve the maximum benefit for the resources available the following referral criteria should be used by referring physicians.

The establishment of these access criteria should be undertaken by the patients’ GP to ensure that only appropriate patients who meet the terms of the policy are referred.

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Woman’s Age 23- 42 years NB: Patients should be informed that any stimulation treatment must take place before the patient’s 43rd birthday

Man’s Age 55 years or younger, if applicable

Woman’s BMI >19 BMI <30

Welfare of Child The welfare of any resulting children is paramount. In order to take into account the welfare of the child, the fertility centre should consider factors which are likely to cause serious physical, psychological or medical harm, either to the child to be born or any other child who may be affected by the birth. This is a requirement of the licensing body, Human Fertilization and Embryology Authority (HFEA)

Family Structure No living children from current or previous relationship(s), including adoptive children but excluding foster children. There need to be an explicit and recorded assessment that the social circumstances of the family unit have been considered within the context of the assessment of the welfare of the child. In all considerations of parental status there should be an explicit statement that children adopted by either partner should have the same status as biological children

Smoking Neither partner is a current smoker

Registered GP The patients are registered with a LLR GP

Consent Written consent to treatment is required from both parties *Any cycle of infertility treatment already undertaken (whether NHS or self-funded) will be taken in to account when determining funding entitlement

Guidance

LLR Intrauterine and Donor Insemination Policy (excluding In Vitro Fertilisation and Intracytoplasmic Sperm Injections) Policy 2016

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Knee Resurfacing

Reference number: ARP 60 Title: Policy for Knee Resurfacing

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Knee Resurfacing

Category

Threshold Criteria

Knee Resurfacing (also known as Partial Knee Resurfacing, Partial Knee Replacement (PKR)) retains the healthy compartments of the knee joint and only replaces the damaged surfaces. Resurfacing may be an option if the arthritic deterioration of the knee is limited to only one or two of the compartments of the knee.

Eligibility

LLR CCGs will only fund this procedure when the following criteria are met.

• The patient has been assessed by Musculoskeletal Services and diagnosed as suffering from end-stage osteoarthritis suitable for referral for consideration of surgery,

AND • The patient has fully engaged with conservative measures for a period of at least six months (clearly detailed throughout the patient’s primary care record or via Musculoskeletal Services’ clinic letters), as detailed within this policy, and this has failed to improve the symptoms of the patient,

AND • The patient: o Is suffering from intense or severe persistent pain with moderate or severe functional impairment when compared to the classification system on the previous page.

OR o Has significant instability of the knee joint with significant functional impairment*,

OR o Has radiological features of severe disease with moderate functional impairments;

OR o Has radiological features of moderate disease with significant functional impairment* or instability of the knee joint and is suffering from. OR o The patient has severe persistent pain that is causing severe functional impairment which is compromising their mobility to such an extent that they are in immediate danger of losing their independence and joint replacement would relieve this, and conservative management as set out in this policy is contra-indicated.

OR Full policy title – version number, draft Page 3 of 4 o The patient is at risk of destruction of their joint of such severity that delaying surgical correction would increase the technical difficulties of the procedure.

Guidance

https://www.bristolccg.nhs.uk/media/medialibrary/2017/10/Knee_Replacement_Surgery_CBA_Policy_v1617 .1.01.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Labiaplasty, Vaginoplasty and Hymen Reconstruction

Reference number: ARP 61

Policy for Labiaplasty, Vaginoplasty and Hymen Title: Reconstruction

1 Version number: Policy Approved by: East Leicestershire and Rutland CCG (ELCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman – Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Labiaplasty, Vaginoplasty and Hymen Reconstruction

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document.

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Laser Treatment

Reference number: ARP 62 Title: Policy for Laser Treatment

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Laser Treatment

Category

Threshold Criteria

Laser therapy can be used to treat skin conditions by targeting intense light energy into your skin to reduce the appearance of abnormal vessels.

Eligibility

LLR CCGs will fund the following • Port wine stains – on the face only (not scalp or neck) • Extensive and severe iatrogenic telangiectasia • Congenital pigmented lesion on the face • Rare genodermatosis e.g. tuberose sclerosis • Translocation of hair bearing skin during surgery but not for excessive hair growth (hirsutism) • Intractable and recurrent pilonidal sinus • Tattoo removal for the following o Result of trauma inflicted against the will of the patient (Rape tattoo) where referral for removal has been sought within one year of the tattoo being performed o Latrogenic e.g. radiotherapy tattoo and dirty tattoo

Referral should include

• Details of condition • Size of cysts/ lesion • Evidence of functional/ trauma experienced • Age • Clinical photographs

Guidance

East Midlands Cosmetic Policy 2017

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Laser Treatment for Myopia

Reference number: ARP 63 Title: Policy for Laser Treatment for Myopia

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Laser Treatment for Myopia

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Lipoma – Removal of

Reference number: ARP 64 Title: Policy for Lipoma – Removal of

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Lipoma – Removal of

Category

Threshold Criteria

Lipomas are harmless soft, fatty lumps that grow under the skin.

Eligibility

Surgical removal of lipoma where: • Lesion at least 4cm

AND • Associated with severe functional disability

OR • Recurrent trauma due to size and/or position

Lipomas located on the body that are over 4cm in diameter or in a sub facial position, which have also shown rapid growth and/ or are painful should be referred to an appropriate sarcoma clinic

Referral should include

• Details of condition • Size of lesion • Evidence of functional/ trauma

Guidance

East Midlands Cosmetic Policy 2017

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Liposuction

Reference number: ARP 65 Title: Policy for Liposuction

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Version Comments Date number (description change and amendments)

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Policy for Liposuction

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Low Back Pain – Surgical Interventions

Reference number: ARP 66 Title: Policy for Low Back Pain – Surgical Interventions

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Boy

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Low Back Pain – Surgical Interventions

Category

Threshold Criteria

Eligibility

The LLR CCGs will only fund the following in accordance with the NICE Guidance (NG59)

Spinal Decompression • For people with sciatica when non-surgical treatment has not improved pain or function AND

• Radiological findings are consistent with sciatic symptoms

Spinal Fusion • NOT ROUTINELY FUNDED for people with low back pain unless as part of a randomised controlled trial

Disc Replacement • NOT ROUTINELY FUNDED for people with low back pain

Guidance https://www.nice.org.uk/guidance/ng59/chapter/Recommendations

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Lower Urinary Tract Symptoms (LUTS)

Reference number: ARP 67 Title: Policy for Lower Urinary Tract Symptoms (LUTS)

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing body

Leicester City CCG( LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Lower Urinary Tract Symptoms (LUTS)

Category

Threshold Criteria

Lower urinary tract symptoms (LUTS) refer to a group of clinical symptoms involving the bladder, urinary sphincter, urethra, and, in men, the prostate.

LUTS are a common problem. The pathway enables that full investigations required are carried out in primary care to ensure that those who need hospital evaluation on are seen quickly, investigated thoroughly and then, wherever possible, passed back to Primary Care, where the majority of LUTS can be managed safely.

Eligibility

LLR CCGs will fund secondary care referral for Lower Urinary Tract Symptoms if the following assessment has been made in primary care

Patients need to be referred via the 2 WW pathway if they have • Raised age related PSA • A hard irregular prostate • Significant haematuria

Patients with one or more symptoms: • Frequency • Nocturia • Difficulty in passing urine • Dribbling

Initial Consultation • History o Medical, emotional, physical, psychological, sexual, and social issues o Review of all current medication (including over the counter and herbal medication) • Exclusion of alternative morbidities o U&E/ eGFR if you suspect renal impairment o Fasting blood sugar o Full blood count o Dip stick urine test • IPSS score (patient must complete the “Quality of Life “ section) • Frequency volume chare to differentiate the type of LUTS • PSA test Discussion of PSA test if appropriate and full consultation carried out with patient before Full policy title – version number, draft Page 3 of 5 undertaking. Postpone PSA test for at least one month after treatment of proven UTI

Two Week Review

• Review the investigations • Review frequency volume chart

Storage Predominant LUTS • Symptoms o Frequency o Urgency • Consider o Supervised bladder training o Anticholinergic drugs o Containment products e.g. pads or collecting devices o External collecting devices (sheath appliances, pubic pressure urinals) o Indwelling catheterisation o Referral to the community continence team

Voiding – predominant LUTS • Symptoms o Hesitancy o Poor Flow • Consider o Alpha blocker o 5-alpha reductase inhibitor +/- alpha blocker (review in 3-6 months) if o Prostate >30g (enlarged) OR

o PSA >1.4mg/ml

For persistent storage symptoms • Consider o Alpha blocker + anticholinergic o Intermittent bladder catheterisation o Where a patient is catheterised urine output must be monitored o If urine output is > or equal to 200 ml/hr patient will need to be admitted for IV fluid support

For patient with other underlying causes identified i.e. obstructive uropathy • Refer to urology

Review in 4-6 week • Improvement in symptoms o Continue treatment • No improvement of symptoms o Discuss possible surgical options and the risks associated with surgery • Refer to Urology if o Patient agrees and expresses a preference for surgery o Bothersome LUTS that does not respond to conservative management or drugs o Retention continues o LUTS are complicated by recurrent or persistent UTI

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Guidance

Right Care- Planned Care – Fourth Wave Implementation Strategy 2016

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Magnetic Resonance Guided Focused Ultrasound for Uterine Fibroids

Reference number: ARP 68 Title: Policy for Magnetic Resonance Guided Focused Ultrasound for Uterine Fibroids Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama – SRP Planned Care

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Policy for Magnetic Resonance Guided Focused Ultrasound for Uterine Fibroids

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Male Breast Reduction

Reference number: ARP 69 Title: Policy for Male Breast Reduction

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Male Breast Reduction

Category

Threshold Criteria

Eligibility

LLR CCGs will fund this procedure is all of the following criteria is met

• Sexual maturation has been reached OR

• In cases of idiopathic gynaecomastia in men under the age of 25 then a period of at least 2 years has been allowed for natural resolution AND

• Screening has been undertaken, prior to referral, for endocrinological and drug related causes AND

• Non-surgical treatments have been tried and have been unsuccessful AND

• BMI is between 18 and 25 and has been within this range for 1 year AND

• Confirmed non-smoker and documented abstinence prior to procedure AND

• Photographic evidence

Men with a history of use of steroids for body building or other enhancement of aesthetic or athletic performance will not be eligible

Any suspicious breast lump should be referred via 2 week wait

This procedure requires PRIOR APPROVAL refer to “The Commissioner – Cosmetic Procedures/ Plastic Surgery CAS” on ERS. And sent to Cosmetic Surgery Request Officer - [email protected] or [email protected]

• Details of condition • BMI and period maintained • Smoking status

Referral should be made on the Male Gynaecomastia Surgery Request Application form. The Cosmetic Surgery Request Officer will acknowledge receipt of the application to the GP and Full policy title – version number, draft Page 3 of 4 patient as well as the outcome. The patient will be asked to attend Body Aspects for a scan where the GP confirms the patient meets the BMI criterion. If the BMI is outside of the criterion she will not be scanned. Once patient has been scanned a report will be sent to the Cosmetic Surgery Request Officer If approved the information will be forwarded to the Plastic Surgery department and an assessment appointment made. If not approved, the GP should discuss the outcome with the patient and alternative options

Guidance

East Midlands Cosmetic Policy 2017 https://prism.leicestershire.nhs.uk/HISCore_PathwayShow.aspx?p=557

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Mandibular/ Maxillary Osteotomy

Reference number: ARP 70 Title: Policy for Mandibular/ Maxillary Osteotomy

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama –SRO Planned Care

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Policy for Mandibular/ Maxillary Osteotomy

Category

Threshold Criteria

Eligibility

The LLR CCGs will only fund this procedure if the following criteria is met • Jaw deformities and malocclusions

o Where there are significant functional and psychological effects on patients.

• Cleft lip and palate, as one aspect of lifelong multidisciplinary treatment to restore form and function

• Obstructive sleep apnoea

o As a last resort when all else has failed.

Guidance

http://www.enhertsccg.nhs.uk/sites/default/files/documents/Jun2017/Guidance%2011%20- %20Mandibular%20or%20Maxillary%20Osteotomy.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Medial Branch Block and Facet Joint Injection

Reference number: ARP 71 Title: Policy for Medial Branch Block and Facet Joint Injection

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire (WLCCG) Governing Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned care Director: Ket Chudasama –SRO Planned Care

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Policy for Medial Branch Block and Facet Joint Injection

Category

Threshold Criteria

Non-radicular (none radiating) back pain is the commonest clinical presentation. Sometimes it is referred to as “mechanical back pain”. It is often the diagnosis for symptoms that are not caused by neural impingement or medically significant other causes.

The National Institute of Clinical Excellence (NICE) is clear in its guidance that intra-articular facet joint steroid injections should not be used in the treatment of pain originating from the lumbar facet joints. However there are a few occasions where facet joint injections can be considered. These are detailed below.

In accordance with the LLR Back Pain Pathway all referrals will go through MSK triage and be assessed by a GP with Special Interests (GPwSI) or Enhanced Scope Physiotherapist.

Eligibility

LLR CCGs will fund medial branch blocks for the management of cervical, thoracic and lumbar back pain in the following clinical situations

• diagnostic procedure leading to radiofrequency denervation of the medial branch if the diagnostic block is positive AND • all conservative management options have been tried and failed o physiotherapy o exercise o pharmacotherapy including analgesia AND • the pain has resulted in moderate to significant impact on daily life OR • if the initial medial branch block has had a proven therapeutic benefit but the patient is not suitable for Radiofrequency Denervation or a Pain Management Programme (e.g. multiple comorbidities, cardiac and respiratory dysfunction, cardiac pacemaker or other nerve stimulator, or frail and elderly) LLR CCGs will fund facet joint injections in the following situations

• In patients who have had a positive outcome from a previous injection • Elderly patients or those with comorbidities where positioning for radio frequency denervation is technically difficult • Patients who have significant anatomical problems where locating the nerve poses a risk to the patient

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Guidance

https://www.nice.org.uk/guidance/ng59

http://www.shropshireccg.nhs.uk/media/1119/value-based-commissioning-policies-former-plcv- v30a-june-17.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Mirena – For the Treatment of Heavy Menstrual Bleeding

Reference number: ARP 72 Title: Policy for Mirena – For the Treatment of Heavy Menstrual Bleeding Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body

Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018

Review Date: November 2021

Document Author: Danah Cadman- Project Manager Planned Care

Director: Ket Chudasama – SRO Planned Care

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Policy for Mirena – For the Treatment of heavy Menstrual Bleeding

Category

Threshold Criteria

This policy applies only to Mirena Devices fitted only for control of heavy menstrual bleeding. As per the section 75 agreement with LCC for the fitting in primary care for menhorrhagia

Mirena for contraceptive purposes are commissioned by Leicester County Council as part of the sexual health service.

Commissioning the fitting of IUDs for menorrhagia and hormone replacement is the responsibility of the CCGs, and is currently managed via a section 75 agreement with LCC.

Eligibility

Insertion and removal of Mirena should only be undertaken in a primary care setting, it is not normally commissioned as a secondary care service unless specific medical issues prevents fitting or removal by primary care or if fitted as part of contraception provided in conjunction with Termination of Pregnancy. Patients requiring a Mirena insertion for family planning purposes should access the community family planning service.

LLR CCGs will only fund a Mirena when all of the following criteria are met

Mirena should be fitted and removed for the management of heavy menstrual bleeding by primary care and not secondary care unless; • It is fitted as part of a surgical procedure in secondary care, i.e. following an endometrial ablation or resection OR

• A medical issue requires the procedure to be performed in secondary care OR

• Fitting is offered following a termination of pregnancy OR

• Insertion OR removal is technically difficult requiring removal under general anaesthesia OR

• Failed fitting in Primary Care OR

• Failed fitting by Sexual Health Service

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• It is unable to be removed in the community

Please note :If facilities and appropriately trained staff are not available to provide a Mirena fitting service in the community – referral to an alternative primary care service or sexual health service to be made

Guidance

http://www.shropshireccg.nhs.uk/download.cfm?doc=docm93jijm4n9662.pdf&ver=16858 /

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Myringotomy with or without Grommets – Children Only

Reference number: ARP 73 Title: Policy for Myringotomy with or without Grommets – Children Only Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama - SRO Planned Care

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Policy for Myringotomy with or without Grommets – Children Only

Category

Threshold Criteria

A myringotomy is an operation to make a tiny cut in the eardrum. Any glue is sucked from the middle ear and if required a grommet is placed in the eardrum. This is to relieve pressure in the ear, caused by a build-up of fluid, drain pus out of the ear.

The procedure is carried out using a short general anaesthetic. The operation is sometimes suggested for children who have hearing problems, keep getting ear infections, have a build-up of mucus in their middle ear, called glue ear.

The guidance applies to children with recurrent ear infections.

Eligibility

LLR CCGs will fund this procedure if the following is met

Referral process for Myringotomy with or without grommets: • Children with suspected OME • Children with Down’s syndrome • Children with cleft palate

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Care pathway 1: Children with suspected OME

Full policy title – version number, draft Page 4 of 6 Care Pathway 2: Children with Down’s syndrome

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Care Pathway 3: Children with cleft palate

Guidance

http://guidance.nice.org.uk/CG60

Right Care- Planned Care- Fourth Wave Implementation Strategy Summary 2016

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Non Cosmetic Nasal Treatment for All Ages

Reference number: ARP 74 Title: Policy for Non Cosmetic Nasal Treatment for All Ages Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021

Document Author: Danah Cadman –Project Manager Planned Care

Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

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Policy for Non Cosmetic Nasal Treatment for All Ages

Category

Threshold Criteria

This policy covers all Non Cosmetic Nasal Procedures including diagnostics, treatment and surgery.

Nasal Conditions Nasal Congestion is the blockage of the nasal passages usually due to membranes lining the nose becoming swollen due to inflammation. This is also known as having a blocked nose. This can be caused by allergies or the common cold.

Nasal Congestion can also result from having an obstruction to the airflow due to a deviated septum. This deviation can cause restrictions on either side (unilateral) or both sides (bilateral) of the nose.

Having a deviated septum is a physical change in the nose cavity which can narrow the nostrils.

Most people have a degree of deviation in their nose and do not require any treatment; however those who develop Nasal Obstruction as a result of a congenital condition or following a traumatic impact on the nose may require treatment to improve airflow.

Snoring is a common complaint amongst those with a degree of Nasal Obstruction / Deviated Septum. In isolation, snoring is not a reason to have surgical treatment to correct the deviation.

Surgical correction of a Deviated Septum is known as Septoplasty. This procedure is carried out within the nose and alone is not aimed at changing the cosmetic appearance of the nose externally Septorhinoplasty

On some occasions the Septum is deviated to such a degree that surgical treatment to correct it will also need to correct the external appearance of the nose and this procedure is called a Septorhinoplasty. A “nose job” commonly refers to the cosmetic correction of the look of the nose and this procedure is called a Rhinoplasty. Some people may have “bumps” on the bridge of their nose and these bumps may impact their comfort, whilst wearing glasses for example. This is considered a Cosmetic request and outside the remit of this policy.

Nasal Polyps

Nasal polyps are common, benign, swellings of the lining of the nose. In some people they may cause no symptoms, but in others they may lead to nasal obstruction, rhinorrhoea (nasal discharge), facial pressure and anosmia (loss of sense of smell). The incidence of symptomatic nasal polyps increases with age and they are more common in men than in women. The cause of nasal polyps is not fully understood but they may be associated with chronic (long-term) inflammation of the lining of the nose (termed 'chronic rhinosinusitis with nasal polyps'). Chronic rhinosinusitis with nasal polyps Full policy title – version number, draft Page 3 of 7 can be treated medically, for example with drugs such as topical (intranasal) steroid sprays, or with surgery, for example a nasal polypectomy with or without endoscopic sinus surgery (ESS). The evidence relating to the effectiveness of different types of surgery versus medical treatment for adults with chronic rhinosinusitis with nasal polyps is of very low quality (ref Cochrane Review).

ENT UK advise: “Polyps respond and shrink using drops or sprays in up to 80% of people. New nasal steroid sprays can be taken to control symptoms for many years as very little is absorbed into the body and they can work well, but many take up to six weeks of treatment before their full effect can be felt.”

Surgical intervention in the treatment of nasal polyps should be considered in patients who fail to improve after a trial of maximal medical treatment. Treatment can include: Antibiotics, Antihistamines, Nasal Douches, Nasal Steroids and Oral Steroids. Functional Endoscopic Sinus Surgery (FESS) involves the clearance of polyps and polypoid mucosa and opening of the sinus ostia (ref EPOS).

The optimal surgical management of nasal polyps has not yet been established. There are very few clinical trials which compare medical and surgical treatment with the extent of surgical resection required to optimize patient outcomes, hence this is largely unknown.

Functional endoscopic sinus surgery (FESS) therefore describes an approach and not a standardized operation. The long-term efficacy of surgery is almost certainly influenced by the regimen of medical treatment prescribed postoperatively and the subsequent compliance with this regimen (EPOS) (Rhinosinusitis and Nasal Polyps (EP3OS) Group, 2012)

XprESS multi sinus dilation system for treating chronic sinusitis NICE have issued in December 2016 guidance on the benefits of using the XprESS in comparison to FESS and concluded that the case for adopting the XprESS multi-sinus dilation system for treating uncomplicated chronic sinusitis after medical treatment has failed is supported by the evidence. Treatment with XprESS leads to a rapid and sustained improvement in chronic symptoms, fewer acute episodes and improved quality of life which is comparable to Functional Endoscopic Sinus Surgery (FESS).

XprESS should be considered in patients with uncomplicated chronic sinusitis who do not have severe nasal polyposis. In these patients, XprESS works as well as FESS, is associated with faster recovery times, and can more often be done under local anaesthesia.

Cost modelling indicates that XprESS is cost saving compared with FESS when treatment is done using local anaesthetic in an outpatient setting. (NICE, 2016)

Inferior Turbinates are soft pieces of tissue within the nose whose function is to increase the surface area of the nasal cavity in order to warm and moisten air passing through the nose. Enlargement of these turbinates, (due to allergy or infection), causes obstruction of the nose.

Trimming these turbinates / turbinate reductions (also known turbinoplasty or turbinectomy) allows you to have more space in the nasal cavity and allows you to breathe more easily.

A Cochrane review from 2010 says that “Inferior turbinate (lining of nose) surgery is a commonly performed procedure in ENT as shrinking the lining may reduce some of the symptoms of allergic rhinitis, particularly nose blockage. This procedure is carried out using a multitude of techniques including cautery, laser and plasma knife. Although unusual, there is the potential for complications such as excessive bleeding and dry nose from these procedures. We set out to identify randomised controlled trials (RCTs) of inferior turbinate surgery compared to continued medical treatment in allergic rhinitis patients in whom medical treatment had failed to relieve symptoms. We also looked Full policy title – version number, draft Page 4 of 7 for RCTs comparing one technique of turbinate surgery with another. Although our search was extensive, we were not able to find any RCTs which met our inclusion criteria. Research, in the form of properly conducted trials comparing various techniques and assessing long-term results and complications, has not yet been done in this field. We therefore conclude that the evidence in the literature is not robust enough about the usefulness of surgery using any technique for this condition” (Cochrane, 2010) & (Cochrane, 2010)

Septal Perforation

The septum, composed of cartilage and thin bone, can develop a hole within the cartilage. This can occur for a number of reasons including nasal septal surgery, autoimmune or vasculitis conditions, trauma, cancer and cocaine use. The damage reduces blood supply in the septum and the cartilage dies which results in a hole developing.

Red flags/ concerning features

Patients presenting with these symptoms should be fast tracked for assessment and treatment if the condition is related to these “red flags” (Appendix A). Patients assessed as not requiring treatment for red flag symptoms should be managed under the normal pathway set out in this policy.

Eligibility

LLR CCGs will only approve funding for treatment if the following criteria is met

RHINOPLASTY

Rhinoplasty intended to only improve the external appearance of the nose is NOT ROUTINELY FUNDED

SEPTOPLASTY/ SEPTORHINOPLASTY

• The patient has o Post traumatic nasal injury causing continuous and chronic nasal airway obstruction associated with septal/ bony deviation of the nose OR

o Nasal deformity secondary to a cleft lip/ palate or other congenital craniofacial deformity AND

• There is a minimum of 6 months documented evidence in the primary care records showing that this condition is causing significant functional impairment as defined by BNSSG* which cannot be managed through conservative methods

SURGICAL TREATMENT for NASAL POLYPS

Diagnosis and treatment for nasal polyps in secondary care is NOT ROUTINELY FUNDED except where the criteria below is met

• Surgical intervention in the treatment of nasal polyps will only be considered in patients who fail to improve after a trial of maximal medical treatment for a period of at least 6 months, and this information is fully documented within the patient’s clinical records

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• There is documented evidence in the primary care records showing that this condition is causing significant functional impairment as defined by BNSSG*

OTHER TREATMENTS NOT ROUTINELY FUNDED

• Diagnosis and/ or treatment of rhinitis, sinusitis and rhinosinusitis including inferior turbinate reduction surgery such as turbinoplasty, radiofrequency ablation and turbinectomy • Surgery to repair septal perforation

Requests for funding for assessment or treatment for conditions that are not listed above should be submitted on an Individual Funding Request application form

*Significant functional impairment is defined by the BNSSG Health Community as

• Symptoms preventing the patient fulfilling routine work or educational responsibilities • Symptoms preventing the patient carrying out routine domestic or carer activities

Guidance

(2003). Allergic Rhinitis and its impact on asthma. ARIA.

Bristol, North Somerset and South Gloucestershire Clinical Commissioning Group (2017). Commissioning Policy Individual Funding Request. Non Cosmetic Nasal Treatment for All Ages

Cochrane. (2010). Inferior turbinate surgery for nasal obstruction in allergic rhinitis after failed medical treatment.

Cochrane ENT Group. Cochrane. (2010). Surgery to the inferior turbinate (lining of the nose) in order to relieve nose block in allergic rhinitis after failed medical treatment. Cochrane Library.

East Midland Cosmetic Policy 2017

EPOS. (2007). European Position Paper. EPOS.

Hull CCG. (2015). Hull CCG Rhinoplasty / Septoplasty/ Septo-Rhinoplasty. Hull CCG.

JM, L., KM, M.-C., PC, B., RM, B., & JS, R. (2016). Outcomes of recalcitrant idiopathic epistaxis in children: Septoplasty as a surgical treatment. The Laryngoscope; Apr 2016.

Jones, M. J. (n.d.). Nasal Polyps. Retrieved 10 12, 2017, from www. ENTUK.ORG: https://www.entuk.org/nasal-polyps

Kempfle JS; BuSaba NY; Dobrowski JM; Westover MB; Bianchi MT. (2016). A cost-effectiveness analysis of nasal surgery to increase continuous positive airway pressure adherence in sleep apnea patients with nasal obstruction. The Laryngoscope; Sep 2016.

Loof S., D. B. (2014). Perioperative complications in smokers and the impact of smoking cessation

Full policy title – version number, draft Page 6 of 7 interventions [Dutch]. Tijdschrift voor Geneeskunde, vol./is. 70/4(187-192.

Mayo Clinic. (2014, September 12). Cosmetic Surgery Risks. Retrieved November 16, 2015, from Mayo Clinic: http://www.mayoclinic.org/tests-procedures/cosmetic-surgery/basics/risks/prc-20022389

Newcastle and Gateshead CCG. (2016). Value Based Commissioning policies. Newcastle and Gateshead CCG.

NICE. (2016, December). XprESS multi sinus dilation system for treating chronic sinusitis. Retrieved from NICE.Org: https://www.nice.org.uk/guidance/mtg30/chapter/1-Recommendations

Northwest CSU. (2016). Greater Manchester EUR Policy Statement Rhinoplasty/ Septoplasty/ SeptoRhinoplasty. Northwest CSU.

Rhinosinusitis and Nasal Polyps (EP3OS) Group. (2012). EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. EPOS.

Sundh, Carolina; Sunnergren, Ola. (2015). Long-term symptom relief after septoplasty. European archives of oto-rhino-laryngology : official journal of the European Federation of Oto-Rhino- Laryngological Societies (EUFOS) : affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery; Oct 2015; vol. 272 (no. 10);

Thelwall, S. P. (2015). Impact of obesity on the risk of wound infection following surgery: results from a nationwide prospective multicentre cohort study in England. Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases, , vol. 21, no. 11, p. 1008.e1.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Ozurdex Intravitreal Implant

Reference number: ARP 75 Title: Policy for Ozurdex Intravitreal Implant

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 221 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama –SRO Planned Care

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Policy for Ozurdex Intravitreal Implant

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Phalloplasty

Reference number: ARP 76 Title: Policy for Phalloplasty

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Version Comments Date number (description change and amendments)

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Policy for Phalloplasty

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Photodestruction of Electrolysis Lesion of Skin

Reference number: ARP 77 Title: Policy for Photodestruction of Electrolysis Lesion of Skin Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Photodestruction of Electrolysis Lesion of Skin

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Prominent Ears (Pinnaplasty)

Reference number: ARP 78 Title: Policy for Prominent Ears (Pinnaplasty)

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama-SRO Planned Care

Version Control and Summary of Changes

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Policy for Prominent Ears (Pinnaplasty)

Category

Threshold Criteria

Ear correction surgery is cosmetic surgery to alter the size or shape of the ears, or pin them back if they stick out. Pinning back the ears is known as pinnaplasty.

Eligibility

Only funded when all of the following criteria are met

• Referral only for children aged 5 to 18 years at the time of referral AND • With significant ear deformity or asymmetry AND • Where the child (not just the parent/ carer) express concern

Guidance

East Midlands Cosmetic Policy 2017

Royal College of Surgeons and British Association of Plastic, Reconstructive and Aesthetic Surgeons – Pinnaplasty Commissioning Guide (2013)

http://www.rcseng.ac.uk/healthcare-bodies/docs/published-guides/pinnaplasty/at_download/file

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Radio Frequency Denervation in the Management of Chronic Back Pain

Reference number: ARP 79 Title: Policy for Radio Frequency Denervation in the Management of Chronic Back Pain Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama –SRO Planned Care

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Policy for Radio Frequency Denervation in the Management of Chronic Back Pain

Category

Threshold Criteria

Radiofrequency denervation, also known as radiofrequency facet or sacroilial joint rhizotomy or facet or sacroilial neurotomy, involves the application of various types of thermal or radiofrequency energy within the spine which results in the destruction of targeted nerves.

This treatment is provided as part of a pain management programme by a specialised pain management service

The following are excluded from this policy • Children up to the age of 18yrs • Patients with back pain secondary to spinal metastases

Eligibility

The LLR CCGs will fund conventional thermal radiofrequency denervation of the facet or sacroiliac for patients with severe chronic pain in the cervical, thoracic or lumbar spinal regions who meet all the following criteria

• The patient is aged 18 years and over AND

• All conservative management options have been tried and failed – physiotherapy, guided exercise programmes, pharmacotherapy including analgesia and muscle relaxants AND

• The patient is experiencing severe pain (assessed by a pain specialist using a visual Analogue Pain Scale) for more than 6 months AND

• The symptoms are not consistent with identifiable pathology including disc herniation and spinal stenosis AND

• Back or neck pain predominates over leg or arm pain AND

• Patient has had 1 medial branch or intra – articular nerve blocks that has provided symptom relief physiologically consistent with medial nerve branch pathology

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Guidance

https://www.nice.org.uk/guidance/ng59/chapter/Recommendations

https://www.westsuffolkccg.nhs.uk/wp-content/uploads/2014/09/T44-RF-Denervation-Policy.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Restless Leg Syndrome

Reference number: ARP 81 Title: Policy for Restless Leg Syndrome

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama –SRO Planned Care

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Policy for Restless Leg Syndrome

Category

Threshold Criteria

Restless legs syndrome (RLS) is a neurological disorder characterized by unpleasant sensations in the legs and an uncontrollable urge to move when at rest in an effort to relieve these feelings. RLS sensations are often described by people as burning, creeping, tugging, or like insects crawling inside the legs. The prevalence across the UK is 3-15% of the population and it can occur in both genders but there may be a slightly higher incidence in females. It can occur at any age, but the severity of the disease increases with age. For each individual the severity of the sensations can vary from uncomfortable to irritating to painful and these sensations are often called paraesthesia (abnormal sensation) or dysaesthesia (unpleasant abnormal sensation).

A diagnosis of Restless legs Syndrome can be made, according to the RLS: UK, if the patient fulfils each of the following criteria • urge to move legs; may be associated with abnormal sensations • symptoms occur at rest or during periods of inactivity • partially or completely relived by moving the limb • nocturnal worsening or occurrence of symptoms at night

Lying down or trying to relax can activate the symptoms and so sufferers, as a result, have difficulty falling asleep or staying asleep. Untreated the condition can lead to daytime exhaustion for the patient and activities of daily living; personal relationships can be severely affected.

If there is uncertainty of diagnosis GPs can seek Advice and Guidance via ERS

Eligibility

LLR CCGs support referral to secondary care when the patient meets the following criteria

• Symptoms should be assessed using the International Restless Legs Syndrome Study Groups Rating Scale Questionnaire (appendix A) to determine the impact on the person’s quality of life o For patients with mild symptoms provide reassurance and promote self-help measures, several listed below o Patients with moderate to severe symptoms

• Non-pharmacological therapy interventions have been exhausted/ excluded o Relaxation exercises o Distraction techniques o Good sleep hygiene o Stretching and massaging affected limb Full policy title – version number, draft Page 3 of 5 o Abstinence from caffeine, nicotine and alcohol o Stop smoking o Moderate exercise o Consider effects of medication that may cause/ exacerbate RLS o Exclude secondary causes e.g. iron deficiency, pregnancy, renal failure

Details regarding pharmacological treatments for Restless Leg Syndrome can be found on the Leicestershire Medicines Strategy Group website https://www.lmsg.nhs.uk/

Guidance

https://cks.nice.org.uk/restless-legs-syndrome#!scenario http://www.lambethccg.nhs.uk/news-and-publications/meeting-papers/south-east-london-area- prescribing- committee/Documents/Clinical%20guidelines%20and%20pathways/Restless%20Legs%20Syndrome %20Treatment%20Pathway%20May%202017.pdf https://www.lmsg.nhs.uk https://www.southworcsccg.nhs.uk

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Appendix A

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Reversal of Sterilisation – Male and Female

Reference number: ARP 82 Title: Policy for Reversal of Sterilisation – Male and Female Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama –SRO Planned Care

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Policy for Reversal of Sterilisation – Male and Female

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Rhinophyma

Reference number: ARP 83 Title: Policy for Rhinophyma

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Rhinophyma

Category

Threshold Criteria

Rhinophyma is a skin disorder characterised by a large, red, bumpy nose. It can occur as part of a phymatous rosacea. The exact cause is not known but is considered to be a sub type of severe rosacea. Although commonly believed to be due to alcohol, there is no link between Rhinophyma and excessive drinking

Although there is no cure for rhinophyma, treatments can be effective in improving the appearance and prevent deterioration.

Treatment of established rhinophyma can be very challenging and can include a combination of different treatment options. Oral treatments do not usually work very well in established rhinophyma, and surgery is often necessary. The aims of surgical treatments are to remove the excess tissue and restore the natural shape of the nose as much as possible by shaving off the extra layers of skin.

Eligibility

The LLR CCGs will support the referral of a patient to secondary care in the following situations

Routine dermatology referral • Persistent symptoms that are causing psychological or social distress • Papulopustular rosacea • Uncertain diagnosis

Referral to a plastic surgeon • Severe phymatous disease • Prominent Rhinophyma

Routine referral to an ophthalmologist • Ocular symptoms are severe • Ocular symptoms fail to respond to maximal treatment in primary care

Urgent referral to an ophthalmologist • Suspected keratitis when there is eye pain, blurred vision or sensitivity to light

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Guidance www.bad.org.uk/leaflets www.patient.info/doctor/rosacea-and-rhinophyma

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Scar Reduction

Reference number: ARP 84 Title: Policy for Scar Reduction

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

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Policy for Scar Reduction

Category

Threshold Criteria

Complete scar removal is not possible, but most scars will gradually fade and become paler over time. A number of treatments are available that may improve a scar's appearance and help make it less visible.

Eligibility

LLR CCGs will only fund scar reduction if the following criteria is met

Repair of, or injection/ application of topical treatment for keloid scars that result from, burns, trauma, keloid formation or surgery when one of the following clinical criteria are met:

• Scar is functionally disabling

OR • Scar results in facial disfigurement

Guidance

East Midland Cosmetic Policy 2017 http://www.shropshireccg.nhs.uk/download.cfm?doc=docm93jijm4n9662.pdf&ver=16858

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Scotopic Sensitivity Syndrome

Reference number: ARP 85 Title: Policy for Scotopic Sensitivity Syndrome

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

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Policy for Scotopic Sensitivity Syndrome

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Scrotal Swelling (Varicocele) - Asymptomatic

Reference number: ARP 86 Title: Policy for Scrotal Swelling (Varicocele) - Asymptomatic Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018

Review Date: November 2021

Document Author: Danah Cadman- Project Manager Planned Care

Director: Ket Chudasama- SRO Planned Care

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Policy for Scrotal Swelling (Varicocele) - Asympromatic

Category

Threshold Criteria

Asymptomatic scrotal swelling is the incidental finding of a swelling or lump that may be associated with minor discomfort. This policy excludes all acute and painful scrotal swelling and inguino-scrotal herniae.

Eligibility

LLR CCGs will support referral and treatments for the following

Primary Care Refer: • testicular torsion as an emergency OR

• presentation of a new varicocele in those beyond teenage years (may be the presentation of kidney cancer ( if a significant varicocele on USS then USS kidney if RIGHT varicocele and or LEFT varicocele for over 40 years old) OR

• children <16 years to a paediatric surgical service OR

• if a testicular tumour is clinically evident — refer directly for an urgent outpatient appointment (within 2 weeks) with a urologist Consider measuring Alpha-fetoprotein (αFP) levels, Beta human chorionic gonadotrophin (βHCG) and Lactate dehydronate (LDH) levels at the time of referral • all uncertain scrotal swellings for routine USS

Following USS: • if a suspected malignancy is found, refer on 2 week wait to urology • reassure patients with Hydrocoele/ Varicocoele/ Epididymal Cyst • only consider repeat USS if there is significant clinical change • refer to urology if there are functional problems • patients should be directed to appropriate supporting information e.g. NHS Choices, patient.co.uk

Secondary Care

Full policy title – version number, draft Page 3 of 4 Varicocoele with functional problems: • consider embolisation if appropriate interventional radiology service is available or alternatively surgery • procedures on varicocoeles are not recommended as a treatment for infertility as they do not improve pregnancy rates

Varicocoele in adolescents: • Varicoceles become more frequent in at the beginning of puberty. Fertility problems will arise in about 20% of affected adolescents. Varicocelectomy is indicated for those patients with a small testis (growth arrest) as testicular catch up growth and improvement in sperm parameters has been reported.

Guidance

Commissioning Guide: Asymptomatic Scrotal Swelling, BAUS, 2013

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Second and Third Specialist Opinion for the Same Condition

Reference number: ARP 87 Title: Policy for Second and Third Specialist Opinion for the Same Condition Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

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Policy for Second and Third Specialist Opinion of the Same Condition

Category

Threshold Criteria

LLR CCGs respect patient’s choice and in some circumstances it will be appropriate to seek another opinion on their condition.

Eligibility

CCGs will only fund a second opinion if

• The patient is able to provide a rational justification for requesting a second opinion • The CCGs will accept the opinion of the patient’s GP that such a referral is justified

CCGs will only fund a third opinion if It would be very unusual for a patient to require a third opinion. It is therefore CCG policy that any such request would need prior approval.

• The patient with the logistical support of their GP would need to provide written justification for such a request that would be considered by the Prior approvals panel. • The fact that the patient disagrees with the two opinions already given is not regarded as justification without substantial supportive evidence • The fact that the patient did not personally like the doctors previously seen would not be a justification

A third opinion for the same condition requires PRIOR APPROVAL. Please follow your CCGs prior approval process.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Sleep Apnoea Referral for Obstruction Sleep Apnoea

Reference number: ARP 88 Title: Policy for Sleep Apnoea Referral for Obstruction Sleep Apnoea Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care

Director: Ket Chudasama- SRO Planned Care

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Policy for Sleep Apnoea Referral for Obstruction Sleep Apnoea

Category

Threshold Criteria

Obstructive Sleep Apnoea/Hypopnoea Syndrome (OSAHS) is part of a spectrum of sleep disordered breathing that also includes upper airway resistance syndrome and simple snoring. More than just a matter of disturbing a partner’s sleep, OSAHS also leads to impaired daytime function, poor work productivity, irritability, depression and loss of libido. The associated wake-time sleepiness can lead to accidents when driving or operating dangerous machinery. Additionally, there is increasing evidence of an association with the metabolic syndrome including obesity, diabetes, hypertension and increased risk of myocardial infarct and stoke. OSAHS has implications for drivers, both category 1 and 2 (HGV, PSV) licence holders

Patients who snore need to be assessed to see if they are likely to have OSAHS, this includes a history and physical examination and completion of the Berlin Questionnaire (to assess risk) and the Epworth Sleepiness Score ( an indication of impaired daytime function).

The Berlin Questionnaire separates patients into high and low risk for OSAHS. It consists of 3 domains; snoring, sleepiness/fatigue and risk factors. A positive response in 2 or more domains is indicative of high risk for OSAHS. Patients may need some help with this questionnaire since a calculation of BMI is required (see Appendix 2, Berlin Questionnaire).

All patients suspected of having OSAHS should complete an Epworth Score questionnaire. Where possible, their partner should be asked to give a second opinion. This is because patients do not always fully appreciate the extent to which they are affected (see Appendix 1, Epworth Sleepiness Score). Any elevation in the ESS has implications for the patient’s safety, life expectancy and quality of life. If not readily attributable to reduced opportunity for sleep, then a referral to a Sleep Centre may be appropriate.

Patients with a normal ESS and low risk on the Berlin Score should not normally be considered for referral to the Sleep Service. They should be provided (where appropriate) with counselling and information leaflets on the self-management of simple snoring, sedative and alcohol avoidance, weight loss, smoking cessation and the use of a mandibular repositioning device (MRD) or mandibular splint. All such patients should also be warned about the dangers of driving while sleepy

Eligibility

LLR CCGs will support referral to the Sleep Centre for the following patients.

All patients considered ‘high risk’ by the Berlin Score should be referred to a Sleep Centre for further Full policy title – version number, draft Page 3 of 4 investigation and possible treatment. A high Epworth Score is an indication of impaired daytime function and may suggest a more urgent referral.

Urgent referral should be considered under the following circumstances: • The combination of severe OSAHS and COPD • Patients with symptoms suggestive of OSAHS who are sleepy while driving or working with machinery, or who are employed in hazardous occupations. • Patients with symptoms suggestive of OSAHS and who have evidence of ventilatory failure.

Guidance

Johns MW. A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991;14:540-5

Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the Sleep Apnoea Syndrome. Annals of Internal Medicine 1999; 131:485-91

Scottish Intercollegiate Guidelines Network (SIGN). Management of Obstructive Sleep Apnoea/Hypopnoea Syndrome in Adults: a national clinical guideline. SIGN guideline 73, 2003. www.sign.ac.ukLLR PCT for UHL 0809 Contract Section C4-4g PCT Questionnaires and information-snoring referral v3 - 0809.doc

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Sterilisation – Female and Male

Reference number: ARP 89 Title: Policy for Sterilisation – Female and Male

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

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Version Comments Date number (description change and amendments)

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Policy for Sterilisation – Female and Male

Category

Threshold Criteria

Both female and male sterilisation is regarded as permanent and reversal of sterilisation is NOT ROUTINELY FUNDED by the LLR CCGs.

Research demonstrates a higher incidence of regret among younger females who undergo sterilisation, therefore careful consideration should be given to long acting reversible contraceptives as these have been shown to be as effective.

Women who request sterilisation and meet the criteria below should be referred to a secondary care provider.

Men requesting a sterilisation (vasectomy) and meet the criteria below should be referred to a primary care vasectomy service if clinically appropriate. The primary care vasectomy service provides vasectomies under LOCAL ANAESTHETIC. Men who have contraindications to local anaesthetic and/ or have coexisting urological conditions which is likely to require scrotal surgery e.g. large hydrocele or large epididymal cyst should be referred to a urology secondary care provider so both procedures can be done at the same time.

Eligibility

LLR CCGs will fund this procedure if the following criteria is met • If the woman is certain her family is complete or that she never wants children AND • The woman has received counselling about her options including consideration of all other forms of long acting contraception. If she has a partner has he considered vasectomy AND • The woman is of sound mental capacity AND • The woman has trialled long acting reversible contraception for at least 12 months e.g. levonorgestrel intrauterine system, etonogestrel, sub dermal implant or Depot Medroxyprogesterone Acetate injection, or a copper IUCD for women with a history of breast or other hormonal cancer OR • The woman declines a trial of long acting reversible contraception after counselling

Full policy title – version number, draft Page 3 of 4 OR • The woman has a medical condition making pregnancy dangerous

Exceptions to this policy

• Where sterilisation is to take place at the time of another procedure i.e. caesarean section • Where there is a contraindication to the use of a long acting reversible contraception • Where there is an absolute contraindication to pregnancy

Eligibility for Male Sterilisation (Vasectomy)

LLR CCGs will fund this procedure if the following criteria are met. Where clinically appropriate this procedure should be performed in a primary care service.

• The man is certain his family is complete or that he never wants children • The man is of sound mental capacity • Has been counselled regarding the permanency of the procedure and other contraceptive options explored

If the man is not suitable to have a vasectomy in primary care, the primary care vasectomy service will facilitate a referral to secondary care.

Exceptions to this policy

• Where sterilisation is to take place at the same time as another scrotal procedure • If the man has any contraindications to local anaesthetic • Where the man has a co-existing urological problem

Guidance

https://www.rcog.org.uk/globalassets/documents/guidelines/consent-advice/consent-advice-3- 2016.pdf

https://www.westsuffolkccg.nhs.uk/wp-content/uploads/2014/09/WSCCG-T26-Policy-Female- Surgical-Interval-Tubal-Sterilisation.pdf

https://www.fsrh.org/documents/cec-ceu-guidance-sterilisation-cpd-sep-2014/

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Surgical Biological Mesh – The Use of

Reference number: ARP 90 Title: Policy for Surgical Biological Mesh – the Use of

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

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Policy for Surgical Biological Mesh – The Use of

Category

Threshold Criteria

Acellular dermal matrices are a relatively new product used in surgical interventions in the UK. Mesh has been used in breast reconstruction to improve aesthetic outcomes and shorten time scale to final results. There was initially a significant rate of complications with the use of biological mesh however as surgical technique has improved and patient selection has become more rational, there have been improvements in outcome. There is still limited research on the use of biological mesh in surgical procedures; however evidence suggests improved aesthetic outcomes, reduced capsular contraction and greater patient satisfaction in breast reconstruction for breast cancer.

Eligibility

LLR CCG will only funded when the following criteria is met for BREAST RECONSTRUCTION SURGERY

• Patients with cancer of the breast, ductal carcinoma insitu and those who are identified as having high risk genes e.g. BRAC 1/ 2, TP53, PTEN AND

• Patient has adequate skin envelope to reduce risk of skin necrosis

Regular audit of patients undergoing breast reconstruction with use of biological mesh as recommended by the joint guidelines from ABS and BAPRAS. Absolute requirement is implant loss of <10%

LLR CCG will NOT fund the use of biological mesh in the following patients

• Patients who are due to undergo chest wall radiotherapy following breast reconstruction • Patients who are currently smoking or have smoked in the last 6 months • Patients undergoing simultaneous axillary clearance

The CCGs advise caution in the following situations

• Patients with a BMI of > 30 • Breast size greater than 600mg (increased risk of infection) • Patients with poorly controlled diabetes

Full policy title – version number, draft Page 3 of 5 LLR CCG will only funded when the following criteria is met for PARA OESOPHAGEAL HERNIA REPAIR

• Patient has large gaps in the diaphragm which are not amenable to simple surgical repair

Biological Mesh is NOT commissioned for • Thoracic surgery • APER/ eLAPE • Hernia repair other than the above • Any other indications

Guidance

Alam, N., Narang, S., Kokerling, F., Daniels, I. and Smart, N. (2016) Biologic Mesh Reconstruction of the Pelvic Floor after extralevator Abdominoperineal excision: A Systematic Review , Frontiers in Surgery, Vol 3, article 9, pp. 1-8.

Becker, H. and Lind, J. (2013) The Use of Synthetic Mesh in Reconstructive, Revision, and Cosmetic Breast Surgery, Aesthetic Plastic Surgery, Vol 5, pp. 914-921.

Bringman, S., Conze, J., Cuccurullo, D., Deprest, J., Junge, K., Klosterhalfen, B., Parra-Davila, E., Ramshaw, B. and Schumpelick, V. (2010) Hernia repair: the search for ideal meshes, Hernia, Vol 14, pp. 81-87.

Coventry and Rugby CCG: Commissioning Policy, The use of Biological and Synthetic Mesh/Equivalent in Surgery. June 2016.

Gschwantler-Kaulich, D., Schrenk, P., Bjelic-Radisic, V., Unterrieder, K., Leser, C., Fink-Retter, A., Salama, M. and Singer, C. (2016) Mesh versus accelular dermal matrix in immediate implant-based breast reconstruction – A prospective randomized trial, European Journal of Surgical Oncology, Vol 42, pp. 665-671.

Hanif, Z., Bradley, A., Hammad, A. and Mukherjee, A. (2016) Extralevator abdominoperineal excision (Elape): A retrospective cohort study, Annals of Medicine and Surgery, Vol. 10, pp. 32-35.

Hanna, K., DeGeorge Jr, B., Mericli, A., Lin, K. and Drake, B. (2013) Comparison study of two types of expander-based breast reconstruction: acellular dermal matrix-assisted versus total submuscular placement, Annals of Plastic Surgery, Vol 70, pp.10-15.

Kim, T. and Cho, H. (2013) The suitability of absorbable mesh insertion for oncoplastic breast surgery in patients with breast cancer scheduled to be irradiated, Journal of Breast Cancer, Vol 16, pp.84-89.

Logan Ellis, H., Asaolu, O., Nebo, V. and Kasem, A. (2016) Biological and synthetic mesh use in breast reconstructive surgery: a literature review, World Journal of Surgical Oncology, Vol 14, Article 121, pp. 1-9.

Martin, L., O’Dohnoghue, J., Horgan, K., Thrush, S., Johnson, R. and Gandhi, A. (2013) Accelular dermal matrix (ADM) assisted breast reconstruction procedures, Joint Guidelines from the Association of Breast Surgery and the British Association of Plastic, Reconstruction and Aesthetic Surgeons.

Full policy title – version number, draft Page 4 of 5 Mavros, M., Athanasiou, S., Alexiou, V., Mitsikostas, P., Peppas, G. andFalagas, M (2011) Risk Factors for Mesh-related Infections After Hernia Repair Surgery: A Meta-analysis of Cohort Studies, World Journal of Surgery, Vol 11, pp. 2389-2398.

Musters, G., Bemelman, W., Bosker, R., Burger, J., van Duijvendijk, P., Etten, B., Geloven, A., Graaf, E., Hoff, C., de Korte, N., Leijtens, J., Rutten, H., Singh, B., can de Ven, A., Vuylsteke, R., de wilt, J., Dijkgraaf, M. and Tanis, P. (2014) Randomized controlled multicentre study comparing biological mesh closure of the pelvic floor with primary perineal wound closure after extralevator abdominoperineal resection for rectal cancer (BIOPEX-study), BMC Surgery, Vol. 14, Issue 58, pp. 1-7.

Musters, G., Klaver, C., Bosker, R., Burger, J., van Duijvendijk, P., van Etten, B., Geloven, A., Graaf, E., Hoff, C., Leijitens, J., Rutten, H., Singh. B., Vuylsteke, R., Wilt, J., Dijkgraaf, M., Bemelman, W. and Tanis, P. (2017) Biological Mesh Closure of the Pelvic Floor After Extralevator Abdominoperineal Resection for Rectal Cancer. A Multicenter Randomized Controlled Trial (the BIOPEX-study), Annals of Surgery, Vol 265, Article 6, pp 1074-1081.

Pestana, I., Campbell, D., Bharti, G. and Thompson, J. (2013) Factors affecting complications in radiated breast reconstruction, Annals of Plastic Surgery, Vol 70, pp. 1065-1077.

Sbitany, H. and Serletti, J. (2011) Acellular Dermis–Assisted Prosthetic Breast Reconstruction: A Systematic and Critical Review of Efficacy and Associated Morbidity, Plastic and Reconstructive Surgery, Vol 6, pp. 1162-1169.

Thames Valley Priorities Committee policy proposal: Biological Mesh. September 2015.

Worcestershire CCPC: Report to Worcestershire CCG Clinical Executive Teams. Funding arrangements for Use of Biological and Synthetic Mesh/Equivalents. January 2017.

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Tonsillectomy and Adenoidectomy

Reference number: ARP 91 Title: Policy for Tonsillectomy and Adenoidectomy

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman- Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

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Policy for Tonsillectomy and Adenoidectomy

Category

Threshold Criteria

Tonsils are located on the sides of the throat and are part of the immune system. They are needed them for the first year of our life, but after that they are redundant. In some people they are over- reactive and become too large. This may cause snoring, mouth-breathing, and even obstructive sleep apnoea. They can also trap bacteria such as strep and cause recurrent strep throat. The most common reason for tonsil removal is obstructive sleep apnoea due to large tonsil size. Other reasons to remove tonsils are recurrent strep throat infections, peri-tonsillar abscess, chronic throat pain, or, in adults, suspicion of cancer. Removing the tonsils does not weaken the immune system. Adenoids are similar to tonsils. They are located at the back of the throat above the palate. They are usually removed in children at the same time as the tonsils because they can also cause blockage of breathing.

Eligibility for Tonsillectomy in Adults and Children

LLR CCGs will fund a tonsillectomy if the following clinical indicators are present

• Peri- tonsillar abscess • Acute upper airway obstruction • Recurrent sore throat where one of the following has been documented o 7 or more episodes in the last year o 5 or more episodes in the last two years o 3 or more episodes in each of the last three years AND o Significant severe impact on quality of life indicated by  Absence from work  Absence from school  Failure to thrive AND one of the following

o Aural temperature of at least 38.3C o Tender anterior cervical lymph nodes o Tonsillar exudates o Positive culture of group A beta haemolytic streptococci o Episodes are disabling and prevent normal function o Tonsillar enlargement leading to symptoms of obstruction

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The LLR CCGs will fund tonsillectomy in sleep apnoea syndrome in children when one or more of the following apply

• Positive sleep study OR • Significant impact on quality of life demonstrated OR • Strong clinical history suggestive of sleep apnoea

Eligibility for Adenoidectomy in Children

The LLR CCGs will fund adenoidectomy in children where the following clinical indications are met

• Children with Otitis Media with Effusion (OME) who meet the NICE recommendations for ventilation tubes (grommets) in the presence of persistent and/or frequent upper respiratory tract infections OR • For sleep disordered breathing in children which is diagnosed clinically. The following impact on development must be documented o behaviour e.g. hyperactivity, daytime somnolence o quality of life e.g. height and weight o nasal obstruction o size of adenoids OR • sleep study (in the presence of excessively large adenoids)

Guidance

Royal College of Surgeons - Commissioning guide: Tonsillectomy (2013). https://www.rcseng.ac.uk/healthcare-bodies/docs/published-guides/tonsillectomy SIGN - Management of sore throat and indications for tonsillectomy (2010). http://www.sign.ac.uk/pdf/sign117.pdf NHS Choices – Quinsy; Tonsillitis http://www.nhs.uk/conditions/Quinsy/Pages/Introduction.aspx http://www.nhs.uk/conditions/tonsillitis/Pages/Introduction.aspx

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Temporo-Mandibular Joint Dysfunction (TMD)

Reference number: ARP 92 Title: Policy for Temporo-Mandibular Joint Dysfunction (TMD) Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

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Policy for Temporo- Mandibular Joint Dysfunction (TMD)

Category

Threshold Criteria

Temporo-mandibular joint disorder (TMD), or TMJ syndrome, is an umbrella term covering acute or chronic inflammation of the temporo-mandibular joint, which connects the mandible to the skull. TMJ surgery referred to in this document excludes arthroscopy as it may be performed for diagnostic reason.

Eligibility

LLR CCGs will only fund treatment if the following criteria is met

Before any dentist or surgeon commences any plan or approach involving surgery, a thorough search for inciting para-functional jaw habits have been performed with the correction of any discrepancies from normal as the primary goal. Referrals must evidence the following treatments:

1. Jaw rest

AND 2. Medications: non-steroidal Anti-inflammatory medications such as aspirin, ibuprofen to control inflammation. Muscle relaxants, such as diazepam may decrease muscle spasms AND 3. Physiotherapy

AND 4. Local anaesthetic

AND 5. Occlusal therapy: a custom made acrylic appliance which fits over the teeth prescribed for night and day to balance the bite, reduce and eliminate teeth grinding or clenching (bruxism)

AND 6. Botulinum toxin injections.

Surgery is only indicated after these medical therapies have failed and is done as a last resort.

TMJ ligament tightening, joint restructuring, and joint replacement are only considered in the most severe cases of joint damage or deterioration.

Absolute contraindications to surgery are: . Active or chronic infection; . Insufficient quantity or quality of bone to support the components;

Full policy title – version number, draft Page 3 of 4 . Systemic disease with increased susceptibility to infection; . Patients with extensive perforations in the mandibular fossa and/or bony deficiencies in . the articular eminence or zygomatic arch that would severely comprise support for the . artificial fossa component; . Partial TMJ joint reconstruction; . Known allergic reaction to any materials used in the components; . Patients with mental or neurological conditions who are unwilling or unable to follow . post-operative care instructions; . Skeletally immature patients . Patients with severe hyper-functional habits (e.g. clenching, grinding etc.)

Guidance

http://www.nice.org.uk/guidance/ipg500/resources/guidance-total-prosthetic-replacement-of-the- temporomandibular-joint-pdf

http://www.islingtonccg.nhs.uk/Downloads/CCG/Policies/QualitySafety/Procedures%20of%20Limited %20Clinical%20Effectiveness.pdf

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Thigh, Buttock and Arm Lift – Excision of Redundant Skin or Fat

Reference number: ARP 93 Title: Policy for Thigh, Buttock and Arm Lift – Excision of Redundant Skin or Fat Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG st Date Issued: 1 December 2018 Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

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Policy for Thigh, Buttock and Arm Lift – Excision of Redundant Skin or Fat

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Tongue Ties (Ankyloglossia) – Division of

Reference number: ARP 94

Title: Policy for Tongue Ties (Ankyloglossia) – Division of

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG(LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

ELRCCG Date of Approval: LCCCG

WLCCG

1st December 2018 Date Issued: Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

Full policy title – version number, draft Page 2 of 3

Policy for Tongue Ties (Ankyloglossia) – Division of

Category

Threshold Criteria

Tongue-tie is a birth defect that affects up to 10% of newborn babies. It's more common in boys than girls.

Normally, the tongue is loosely attached to the base of the mouth with a piece of skin called the lingual frenulum. In babies with tongue-tie, this piece of skin is unusually short and tight, restricting the tongue's movement. This may prevent the baby feeding properly.

Treatment is not necessary if the baby has a piece of skin connecting the underside of their tongue to the floor of their mouth, but they can feed without any problems. However, where there are feeding problems a procedure called tongue-tie division can be performed.

Tongue-tie division involves cutting the short, tight piece of skin connecting the underside of the tongue to the floor of the mouth. It's a simple and almost painless procedure that usually resolves feeding problems straight away.

Eligibility

LLR CCGs will fund division of tongue ties in the following circumstances

• Baby is over 28 days of age AND

• Baby has had a feeding assessment and support from the Infant Feeding Team at UHL or LPT

Guidance https://www.cambridgeshireandpeterboroughccg.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=9720 http://www.gloucestershireccg.nhs.uk/wp-content/uploads/2015/08/Tongue-tie-division- 16.05.17.docx https://www.nice.org.uk/guidance/ipg149/resources/division-of-ankyloglossia-tonguetie-for- breastfeeding-pdf-1899863228061637 http://staff.bhamsouthcentralccg.nhs.uk/plans-and-policies/doc_download/441-tongue-tie- ankloglossia-commissioning-policy-january-2014

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Topical Negative Pressure (TNP) for Wound Closure

Reference number: ARP 95 Title: Policy for Topical Negative Pressure (TNP) for Wound Closure Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021

Document Author: Danah Cadman-Project Manager Planned Care

Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

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Policy for Tonsillectomy and Adenoidectomy

Category

Threshold Criteria

Eligibility for Tonsillectomy in Adults and Children

LLR CCGs will fund a tonsillectomy if the following clinical indicators are present

o Oral temperature of at least 38.3C o Tender anterior cervical lymph nodes o Tonsillar exudates o Positive culture of group A beta haemolytic streptococci o Episodes are disabling and prevent normal function o Tonsillar enlargement leading to symptoms of obstruction

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The LLR CCGs will fund tonsillectomy in sleep apnoea syndrome in children when one or more of the following apply

• Positive sleep study OR • Significant impact on quality of life demonstrated OR • Strong clinical history suggestive of sleep apnoea

Eligibility for Adenoidectomy in Children

The LLR CCGs will fund adenoidectomy in children where the following clinical indications are met

Guidance

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Trigger Finger

Reference number: ARP 96 Title: Policy for Trigger Finger

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

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Policy for Trigger Finger

Category

Threshold Criteria

Trigger finger is a condition that affects one or more of the hand's tendons, making it difficult to bend the affected finger or thumb.

If the tendon becomes swollen and inflamed it can 'catch' in the tunnel it runs through (the tendon sheath). This can make it difficult to move the affected finger or thumb and can result in a clicking sensation.

Trigger finger is also known as stenosing tenosynovitis or stenosing tenovaginosis. It usually affects the thumb, ring finger or little finger. One or more fingers can be affected, and the problem may develop in both hands. It's more common in the right hand, which may be because most people are right-handed.

Symptoms of trigger finger can include pain at the base of the affected finger or thumb when you move it or press on it, and stiffness or clicking when you move the affected finger or thumb, particularly first thing in the morning.

Eligibility

LLR CCGs will fund release of a trigger finger in the following circumstance

• Severe Symptoms Refer for surgical assessment

• Moderate Symptoms 6 months of symptoms – during this time no response to conservative management e.g. splinting and analgesia minimum of 1 steroid injection

• Mild Symptoms Treat with simple analgesia

Definitions of symptom severity below

Full policy title – version number, draft Page 3 of 4 Mild Moderate Severe Clinical Swelling +/- pain with As for mild but also Fixed contraction of the Presentation intermittent catching or difficulty in actively digit is present clicking of the digit on extending the digit and flexion/ extension but need for passive finger the digit is fully mobile extension

Guidance

British Society for Surgery of the Hand - Recommendations for Treatment and BSSH - Evidence for Surgical Treatment (BEST): Trigger Finger (Thumb): Optimal number of steroid injections (2011) http://www.bssh.ac.uk/patients/commonhandconditions/triggerdigits http://www.nhs.uk/conditions/Trigger-finger/Pages/Introduction.aspx

Right care – Planned Care – Fourth Wave Implementation Strategy 2016

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Ultrasound for Low Intensity for Bone Healing

Reference number: ARP 97 Title: Policy for Ultrasound for Low Intensity for Bone Healing Version number: 1 Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG) Governing Body Leicester City CCG (LCCCG) Governing Body West Leicestershire CCG (WLCCG) Governing Body Date of Approval: ELRCCG LCCCG WLCCG Date Issued: 1st December 2018 Review Date: November 2021 Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

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Policy for Ultrasound for Low Intensity for Bone Healing

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Uterovaginal Prolapse

Reference number: ARP 98 Title: Policy for Uterovaginal Prolapse

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

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Policy for Uterovaginal Prolapse

Category

Threshold Criteria

Pelvic organ prolapse (POP) refers to abnormal descent/ herniation of one or more of the pelvic organs as a result of failure of ligamentous and fascial supports, resulting in the protrusion of the organ beyond its normal anatomical confines. Prolapse can occur in the anterior, middle/apical or posterior (rectocele) compartment of the pelvis. POP development is multifactorial, with vaginal child birth, advancing age, and increasing body-mass index (BMI) the most consistent risk factors.

Diagnosis is usually clinical and based on history and pelvic (speculum) examination, to establish the compartments affected (classification of the prolapse) and defines the extent of the prolapse (grading of severity/degree).

Eligibility

LLR CCGs will fund this treatment if the following criteria is met • Conservative Management has failed AND • In cases of mild to moderate symptomatic cystoceles where trial of a pessary has failed OR • Moderate or severe symptomatic prolapse (including those combined with urethral sphincter incompetence or urinary/ faecal incontinence

Guidance

http://www.bsug.org.uk/ http://www.enfieldccg.nhs.uk/Downloads/Listening-to- you/AEBM%20consultation/prolapse/North%20West%20London%20CCGs%20Uterovaginal%20Prol apse%20Policy%20from%20Hounslow%20CCG%20Website.pdf https://www.rcog.org.uk/

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Vaginal Pessaries

Reference number: ARP 99 Title: Policy for Vaginal Pessaries

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG(ELRCCG)

Governing Body

Leicester City CCG (LCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

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Policy for Vaginal Pessaries

Category

Threshold Criteria

A vaginal pessary is a plastic device that fits into the vagina to help support the uterus, vagina, bladder, or rectum. The pessary is most often used for prolapse of the uterus

Eligibility

LLR CCGs will only funded in the following circumstance

• Insertion and replacement of vaginal pessary should be done in a primary care setting; it is not commissioned as a secondary care service. This does not include technically difficult pessaries such as shelf pessaries.

• There is no restriction applied to the incidental first fitting of ring pessaries in secondary care if the patient has been referred for a separate reason, however patients should not be referred specifically for the first fitting of ring pessaries.

Guidance

http://www.erewashccg.nhs.uk/modules/downloads/download.php?file_name=526

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Varicose Veins – Surgical Treatment of

Reference number: ARP 100 Title: Policy for Varicose Veins – Surgical Treatment of

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

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Policy for Varicose Veins – Surgical Treatment of

Category

Threshold Criteria

Varicose veins are swollen and enlarged veins that usually occur on legs and feet. They may be blue or dark purple and are often lumpy, bulging or twisted in appearance.

Symptoms include • Aching, heavy and uncomfortable legs • Swollen feet and ankles • Burning or throbbing legs • Muscle cramp in legs particularly at night • Dry, itchy and thin skin over the affected vein

Eligibility

LLR CCG will fund treatment of varicose veins (by endothelium ablation, foam sclerotherapy or surgical stripping) only when one, or more, of the following clinical criteria are met *: a. Varicose eczema b. Lipodermatosclerosis or a varicose ulcer c. At least two episodes of documented superficial thrombophlebitis d. A major episode of bleeding from the varicosity.

*These criteria equate approximately to Clinical, Etiologic, Anatomic and Pathophysiologic (CEAP) stage C4 onwards or Class 4 & 5 of the Nottingham/Derby Guidelines (published 2001) ‘Varicose Veins - who and what to treat’.

For those patients that did not meet the policy criteria (i.e. CEAP 2-3) compression hosiery and lifestyle advice could be offered. Given the natural history of varicose veins to progress in some patients, a patient could be referred at a later date if they developed clinically so that they met the criteria.

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Guidance

East Midlands Cosmetic Policy 2017

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Venous Angioplasty for MS

Reference number: ARP 101 Title: Policy for Venous Angioplasty for MS

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCC) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama – SRO Planned Care

Version Control and Summary of Changes

Version Comments Date number (description change and amendments)

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Policy for Venous Angioplasty for MS

The LLR CCGs do NOT ROUTINELY FUND this treatment. However the treatment will be funded in the following circumstances

The INDIVIDUAL FUNDING REQUEST process, forms and guidance are available via PRISM, under Individual Funding Request (IFR)

The panel will focus on the following

*This process is currently under review and any agreed changes will be reflected in this document

Full policy title – version number, draft Page 3 of 3

Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Vitiligo

Reference number: ARP 102 Title: Policy for Vitiligo

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

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Policy for Vitiligo

Category

Threshold Criteria

Vitiligo is the complete loss of pigmentation arising in discrete patches of skin. It occurs in approximately 1% of the world’s population. The incidence appears to be higher in darker – skinned individuals.

Eligibility

LLR CCGs will only fund secondary care treatment where the following criteria is met

• Patient is aged 18 years old • Greater than 20% of body surface is affected OR

• Segmental Vitiligo

If there is diagnostic uncertainty please seek further advice via Advice and Guidance (on ERS)

Patients with vitiligo can be referred to the UHL Camouflage Clinic if the following criteria are met

Referral criteria:

• >20% body surface area • Segmental Vitiligo

Guidance http://www.pcds.org.uk/clinical-guidance/vitiligo https://prism.leicestershire.nhs.uk/HISCore_PathwayShow.aspx?p=1362

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Leicester City Clinical Commissioning Group West Leicestershire Clinical Commissioning Group East Leicestershire and Rutland Clinical Commissioning Group

Policy for Voice Box Surgery

Reference number: ARP 103 Title: Policy for Voice Box Surgery

Version number: 1

Policy Approved by: East Leicestershire and Rutland CCG (ELRCCG)

Governing Body

Leicester City CCG (LCCCG) Governing Body

West Leicestershire CCG (WLCCG) Governing

Body

Date of Approval: ELRCCG

LCCCG

WLCCG

Date Issued: 1st December 2018

November 2021 Review Date: Document Author: Danah Cadman-Project Manager Planned Care Director: Ket Chudasama- SRO Planned Care

Version Control and Summary of Changes

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Policy for Voice Box Surgery

Category

Threshold Criteria

Eligibility

LLR CCGs will fund surgery for patients who meet the following criteria: Conservative approaches should have been attempted before surgical intervention is considered. Every attempt should be made to identify and eliminate causative factors such as stress, smoking, and alcohol. Drink plenty of clear fluid to avoid a dry throat. Rest the voice completely for two to three days. The speech therapist plays an important role in the assessment and treatment of patients with voice disorders, e.g. Reinke’s oedema, vocal cord nodules and voice misuse. The therapy will take some weeks or months before any improvements are noticed and so the patient must be highly motivated. The patient has dysphonia, defined as: • Their voice has unexpectedly changed (in terms of quality, pitch, loudness or vocal effort) • The voice change has limited their ability to communicate with others • Their symptoms prevent them fulfilling vital work, domestic or carer activities. AND • The patient has completed a course of voice therapy but has a significant continuing health need. AND • Dysphonia is due to organic pathology for which surgical intervention is very likely to be effective. • Surgical management may be considered if all other conservative methods have failed and the dysphonia is continuing to cause significant issues. Note: Voice box surgery is not commissioned as part of the Gender Dysphoria Pathway.

Guidance

https://www.gloucestershireccg.nhs.uk/about-us/funding-treatment/interventions-not-normally- funded/effective-clinical-commissioning-policy-list/

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