Policy for Leicester, Leicestershire and Rutland Approved Referral Pathways

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1 INTRODUCTION

This policy describes the clinical threshold and exclusion criteria which the Leicester, Leicestershire and Rutland (LLR) Integrated Care Board (ICB) has agreed to for planned procedures and treatments contained within this policy. Since initial ratification in 2018 the policies have been reviewed.

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

    The policies were previously known as Approved Referral Pathways, to avoid misinterpretation LLR ICB have taken feedback and renamed each as LLR Policies.

    All reviewed policies are available @  https://leicesterleicestershireandrutland.icb.nhs.uk/your-health/healthcare-and-treatment-policies/

    1.1 BACKGROUND

    This policy document has been agreed to and is supported by NHS Leicester, Leicestershire and Rutland ICB

    The policies aim 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.

    Integrated Care Boards (ICB) 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 the ICB to prioritise its resources using the best evidence about what is clinically effective and to provide the greatest proven health gain.

    1.2 PRINCIPLES

    These have been made in consultation with primary and secondary care clinicians, public health and patient representatives and revised in accordance to the principles set out below, alongside the national Evidence Based Intervention policies:

    • Clear evidence of clinical effectiveness.
    • Clear evidence of cost effectiveness.
    • The cost of treatment to the patient has been taken into 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.

    This policy summarises the planned procedures and treatments that the LLR ICB will either not fund or will fund when the patient reaches a specified clinical threshold. These thresholds were agreed in consultation with clinicians from University Hospitals Leicester (UHL) and former CCG and current ICB clinical leads.

    The policies are categorised as either:

    • Not routinely funded.
    • Threshold Criteria.

    1.3      NOT ROUTINELY FUNDED TREATMENT OR PROCEDURE

    This is a group of treatments or procedures that the LLR ICB does not fund, as not having the treatment or procedure will not have a negative impact on the patient’s physical or mental wellbeing.

    However, the LLR ICB will fund these treatments/ procedures in the following circumstances-

    • Post- physical 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.
    •  Treatment will be funded if an Individual Funding Request (IFR) application proves there to be an exceptional clinical need, which is also supported by the ICB.

    1.4      THRESHOLD CRITERIA FOR TREATMENT OR PROCEDURE

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

    1.5      INDIVIDUAL FUNDING REQUEST (IFR)

    There may be times where there it is clinically appropriate to fund a procedure which is NOT ROUTINELY FUNDED. The LLR ICB 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:

    • 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?

    1.6 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.

    The referral process can be found within PRISM web, all required information must accompany the referral and sent to lcr.ifr@nhs.net

    A panel comprising of a Public Health Consultation, GP and Plastic Surgery Consultant meet bimonthly 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.

     1.7      EQUALITY AND QUALITY IMPACT ASSESSMENTS

     The LLR ICB has assessed the impact of the policies on the population of LLR where they have been major changes to the policies

    1.8      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 EBI activity data.
    • Post activity monitoring through adhoc clinical audits.

    2.0 NOT ROUTINELY FUNDED

    The following table lists all the LLR Approved Referral pathway that are NOT routinely funded.

    1.Botulinum Toxin for Wrinkles
    2.Breast Uplift (Mastopexy)
    3.Calf Augmentation
    4.Cheek/ Chin Implants
    5.Cholecystectomy – Asymptomatic
    6.Collagen Implant
    7.Complimentary Therapies
    8.Correction of Nipple Inversion
    9.Dermabrasion Laser Resurfacing
    10.Earlobe Repair
    11.Endoscopic Thoracic Sympathectomy
    12.Excision of Skin for Cosmetic Indications
    13.Face Lift
    14.Fat Grafts
    15.Gender Reassignment
    16.Gluteal Augmentation
    17.Hair Depilation for Excessive Growth
    18.Hair Transplantation
    19.Labiaplasty, Vaginoplasty and Hymen Reconstruction
    20.Laser Treatment for Myopia
    21.Liposuction
    22.Magnetic Resonance Guided Focused Ultrasound for Uterine Fibroids
    23.Phalloplasty
    24.Photodestruction of skin
    25.Reversal of Sterilisation
    26.Thigh Buttock and Arm Lift
    27.Ultrasound for Low Intensity Bone Healing

    3 THRESHOLD CRITERIA

    The following table lists all the LLR Approved Referral Pathways that have clinical threshold criteria.

    1.Abdominal Hernia
    2.Abdominoplasty
    3.Actinic Keratosis
    4.Alopecia
    5.Arthroscopy of the Knee
    6.Benign Skin Lesions
    7.Breast Asymmetry
    8.Breast Implant Removal and Reinsertion
    9.Breast Reduction
    10.Brow lift
    11.Bunions
    12.Carpal Tunnel
    13.Cataracts
    14.Chalazion
    15.Circumcision – Adult Male
    16.Congenital Pigmented Lesion of the Face
    17.Cryopreservation – Gamete/ Embryo
    18.Dupuytren’s Disease
    19.Ear Wax Removal
    20.Endo Vascular Aneurysm Repair
    21.Endoscopy for Dyspepsia
    22.Epidermoid Pilar Cyst
    23.Epidural Injections for Radicular Pain
    24.Erectile Dysfunction
    25.Facet Joint Injection for Non-Radicular Pain
    26.Facial Hyper Pigmentation of the Face
    27.Fungal Nail Infection
    28.Ganglion
    29.Gastric Fundoplication for Chronic Reflux Oesophagitis
    30.Grommet Insertions – Adults
    31.Hip and Knee Replacement
    32.Hip Arthroscopy
    33.Hip Resurfacing
    34.Hybrid Knee Replacement Revision
    35.Intraocular Lens Implant
    36.Intra Uterine Insemination and Donor Insemination
    37.Knee Resurfacing
    38.Laser Treatment
    39.Lipoma
    40.Lower Back Pain – Surgical Intervention
    41.Lower Urinary Tract Symptoms
    42.Male Breast Reduction
    43.Mandibular Maxillary Osteotomy
    44.Medial Branch Block and Facet Joint Injection
    45.Myringotomy with or without Grommets – Children Only
    46.Non-Cosmetic Nasal Treatment – All Ages
    47Prominent Ears
    48.Radio Frequency Denervation in the Management of Chronic Back Pain
    49.Restless Leg Syndrome
    50Rhinophyma
    51.Scar Reduction
    52.Scrotal Swelling Asymptomatic
    53.Second and Third Specialist Opinion
    54.Sleep Apnoea Referral
    55.Sterilisation – Female and Male
    56.Surgical Biological Mesh – the use of
    57.Tonsillectomy and Adenoidectomy
    58.Temporomandibular Joint Dysfunction
    59.Tongue Ties
    60.Topical Negative Pressure
    61.Trigger Finger
    62.Uterovaginal Prolapse
    63.Vaginal Pessaries
    64.Varicose Veins
    65.Vitiligo
    66.Voice Box Surgery
    67.Arthroscopic Shoulder decompression for subacromial pain

    ARP 1 Review Date: 2027


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