Betsi Cadwaladr University Local Health Board ... - Health in Wales

Betsi Cadwaladr University Local Health Board 

Individual Patient Commissioning 

Standard Operating Procedure 

Authors: Dr Martin Duerden 

Medical Director Conwy - BCUHB 

Dr Fraser Campbell 

Medical Director Gwynedd - BCUHB 

Dr Medwyn Williams 

Medical Director Anglesey - BCUHB 

Mr Damian Heron Director 

North Wales Cancer Network 

Dr Matthew Makin Chief of Staff 

Cancer CPG 

Dr Rob Atenstaedt 

Consultant in Public Health Medicine 

Public Health Wales 

Mr Andrew Jones 

Director of Public Health 

BCUHB 

Based upon: Previous ECR/NCA policies for 

Anglesey LHB 

Conwy LHB 

Denbigh LHB 

Gwynedd LHB 

Flintshire LHB 

Wrexham LHB 

Date : February 2010 

Review Date: March 2011 

Approved by: BCU LHB Board

INDEX OF CONTENTS 

SECTION DESCRIPTION PAGE 

1 Introduction & Definitions 3-5 

2 Legal & Ethical Framework 5-8 

3 Funding Application Procedures 9-14 

4 Child Protection Issues 14 

5 Entitlement of Patients to Treatment Overseas 15 

6 Appeals Process 16-18 

7 Audit, Monitoring and Review Arrangements 18 

8 Communication Strategy 19-20 

Appendix 1 Low Effectiveness Procedures (LEPs) 21 

Appendix 2 Application Request Proforma 60 

Appendix 3 IPC Panel Checklist 64 

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Section 1 - Introduction and Definitions 

1.1 Betsi Cadwaladr University Local Health Board is responsible for the 

management of individual patient specialist requirements, not dealt with under the 

normal referral routes via primary or secondary care. Process and criteria must be 

consistently adopted and adhered to across the Local Health Board to facilitate 

decisions following requests made by appropriate clinicians and manage and monitor 

the individual cases. 

1.2 The priorities for modernising the NHS should be underpinned by the careful 

management of overall NHS resources to ensure people have access to high quality 

services and care, regardless of where they live. Consequently, the Local Health 

Board needs to continuously improve the cost effectiveness of the services provided, 

thereby securing the greatest health gain from the resources available. In order to 

achieve this, funding decisions on individual patient services should be based on 

evidence of both the clinical effectiveness of services, together with an examination 

of the impact of specific high cost services or treatments on the wider ability to deliver 

care for the whole community. 

1.3 Each case will be dependent on assessment of its own merits, in accordance 

with the criteria of the LHB. It is therefore necessary for the LHB to develop and 

maintain a clear, transparent and explicit mechanism to assist in the decision making 

process for these cases. 

1.4 The mechanism in place must ensure that, where possible, decisions are 

made quickly to enable patients and referring clinicians to either implement proposals 

or find alternatives to requests where the application does not receive a positive 

outcome. However, the onus is on the referring clinician to ensure sufficient 

information regarding a particular request is made available to avoid unnecessary 

administrative delay. 

1.5 This procedure presents the approach to be adopted by the Betsi Cadwaladr 

University Local Health Board in receiving and considering requests for funding of 

patient treatments/services that fall within the following categories: 

• Extra Contractual Referrals (ECR); 

• Non Contracted activity (NCA); 

• Named Patient Contracts (NPC); 

• Named Patient Variations (NPV) 

• Low Effectiveness Procedures (LEPs) 

• High Cost Drugs 

• Entitlement of Patients to Treatments Overseas 

1.6 All these categories of treatments and services would be funded from current 

Local Health Board revenue and thus represent an in-year financial risk to the LHB. 

1.7 Under the new proposals for the planning and commissioning of tertiary 

services, funding of specialist procedures previously managed by Health Commission 

Wales (HCW) will transfer to the LHB and be administered by the new national 

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arrangements for specialist commissioning under the Welsh Health Specialised 

Services Committee (WHSSC). However, as these arrangements have not yet been 

finalised, it is assumed that any funding requests for services currently commissioned 

by HCW will continue to be processed by HCW. This will be until such time that the 

new arrangements for tertiary services are in place at which point this procedure will 

be amended accordingly. 

Extra Contractual Referrals (ECR) 

1.8 Treatments or Services provided by an independent or private health service 

provider are termed extra contractual referrals or ECR. 

Non Contracted Activity (NCA) 

1.9 Treatments or Services provided by other NHS organisations with which the 

Local Health Board does not hold an existing Long Term Agreement (LTA) or 

contracts, are termed non contracted activity or NCA. 

1.10 Elective and non emergency NCAs need prior authorisation from the LHB and 

should be considered on an individual case by case basis. However, emergency or 

immediately necessary treatments do not need prior authorisation from the LHB and 

although these tend to be low volume, they are funded from current LHB revenue and 

so therefore present an in-year financial risk for the LHB. 

Named Patient Contacts (NPC) 

1.11 Treatments or Services by an NHS organisation which is prepared to provide a 

specific treatment/service outside the normal LHB contracts are termed Named 

Patient Contacts or NPC. This mechanism may be used where a provider is 

unwilling, or it is inappropriate, to use the NCA process because of high and/or 

variable costs involved. This will often apply to specialised services or new services 

being offered by the NHS organisation. 

Named Patient Variations (NPV) 

1.12 Treatments or Services by an NHS organisation which are variations to an 

existing LTA or contract and which may involve additional funding to support 

enhanced service levels/treatments to individual patients are termed Named Patient 

Variations (NPV) 

Low Effectiveness Procedures (LEPs) 

1.13 Appendix 1 lists clinical interventions of limited or unknown clinical value. 

These interventions are routinely considered to be of low priority and are not normally 

used by the NHS. These interventions have been split between those that should not 

be used in any circumstance and those that should not be used except under strict 

criteria. The latter are subdivided between lower volume (20/year) treatments, according to an analysis across North Wales 

undertaken in 2009 by Public Health Wales 1 . Where applicable the specific 

circumstances/strict criteria under which use can be considered by the UHB, are set 

out together with reference links to the available evidence. Procedures will be subject 

to the process outlined in Section 3 of this policy. In addition, it will be necessary for 

procedures of higher volume to be subject to investigation and continuous review to 

ensure that the UHB position and interpretation of evidence continues to be 

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consistent and appropriate. This will involve appropriate clinical engagement 

processes. 

High Cost Drugs 

1.14 The priority for the LHB is to provide treatment in accordance with NICE 

technology appraisals and All Wales Medicines Strategy Group (AWMSG) approval 

status. It is important to recognise that drugs and procedures not yet reviewed by 

either AWMSG or NICE will not normally be provided, nor will drugs or technologies 

rejected for use by AWMSG or NICE, except under exceptional circumstances. In 

such circumstances, the patient’s clinician must request funding prior to commencing 

treatment through the process outlined in this paper. For patients receiving specific 

high cost treatments, these would be covered by the Named Patient Contracts or 

Variations as above. 

Entitlement of Patients to Treatment Overseas 

1.15 This is covered in Section 5 of this policy 

Section 2 - Legal and Ethical Framework 

2.1 The term ‘services’ will be used when referring to treatment, investigation, 

interventions and other care provided by the NHS. However, many services are not 

included in LTAs and require prior approval. The Local Health Board commissions 

the majority of treatment, investigations, interventions and care through agreed 

contracts with other NHS organisations. 

2.2 The National Health Service is defined within in the National Health Service 

Acts. This places a duty on the Secretary of State for Health (the First Minister in 

Wales) to continue the promotion of a comprehensive health service designed to 

secure health improvement in England and Wales. 

2.3 The Local Health Board make decisions within the parameters of its legal 

powers and duties, such as set out in the NHS Act 1977 and subsequent NHS 

legislation, the Human Rights Act 1998, the Articles of the Human Rights Convention 

and in accordance with Welsh Assembly Government (WAG) guidance. This legal 

framework places duties and obligations upon the LHB to exercise its discretion over 

the services that should be provided. Legally the LHB should seek to provide 

comprehensive services to the extent that they are considered necessary to meet all 

reasonable requirements. These services should be free to users at the point of 

entry (except where there are defined charges) within a finite resource and in 

accordance with the funding which has been made available by the Welsh Assembly 

Government. 

2.4 Health decisions may be subject to legal challenges, which could have 

significant financial consequences for the LHB. A patient could apply for a judicial 

review of an unfavourable decision by the LHB in respect of that individual’s care, 

which may be considered on the grounds of illegality, procedural impropriety or 

irrationality. These are described below: 

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Legality 

Does the LHB have the power to take the action proposed? 

Would the proposed decision put the LHB in breach of its procedures? 

Was the decision taken by the right person or people? 

Was there consultation on the decision? 

Is there over adherence to a rigid policy or failure to consider the 

individual case against the context of the resources available? 

Would the decision be in breach of the Human Rights Act? 

Procedural Propriety 

Rationality 

Are the procedures used fair to all parties? 

Is there a danger that the LHB could breach legitimate expectations 

(promises made) of any groups? 

Were relevant policies followed? 

Has the decision been made in an arbitrary manner? 

Has the LHB acted in a way that no other reasonable LHB would act? 

Is the decision setting any untenable precedents? 

Is there sufficient conflict of opinion to justify the opinion being taken by 

a higher authority or through legal processes? 

2.5 The decision making process is designed to eliminate concerns about 

illegality, procedural impropriety or irrationality by making the process clear and 

transparent. 

2.6 This is particularly important: 

When other LHBs have made a different decision on a specific topic. 

When limiting access to specific services or treatments. 

When setting priorities. 

When the evidence is not completely clear and unambiguous. 

2.7 The Individual Patient Commissioning procedure is founded on a set of core 

principles to ensure that a transparent and reasonable ethical process governs the 

decision making process concerning funding decisions for the categories of 

treatments or services outlined in section 1. 

2.8 These principles include: 

i) Benefit versus harm: 

Evidence that a treatment or service confers a benefit and is the most 

appropriate treatment at this time should be considered 

Decisions should be taken on an individual named patient basis. 

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The default position should be that a treatment outlined in section 1 is not 

offered unless all other available and approved options for treatment 

under LTAs have previously been explored by the referring clinician. 

For all applications, sufficient medical history should be made available 

and reviewed. 

For all applications, evidence of the effectiveness of the treatment or 

service should be considered from a variety of sources including national 

guidance (such as NICE guidance), other sources of clinical evidence 

(such as from the Cochrane Centre) and Public Health Wales as 

appropriate. 

For all applications, other options for treatment should have been 

considered by the referring clinician prior to the request for funding being 

made. 

For all applications, the prognosis of the patient should be considered. 

Where the application is made for drug therapy, existing 

recommendations by NICE and/or the All Wales Medicines Strategy 

Group must be taken into account. 

ii) Equity/ Justice: The LHB should aim to provide equal access to treatments 

for all their patients, based on need: 

The LHB will aim to provide equal access to treatments or services for all 

their patients based on need. 

The LHB has a statutory duty to achieve financial balance and decisions 

to limit access to treatments or services legitimately include aspects 

around financial costs. Decisions to treat inevitably divert resources from 

other health care options. 

Both cost effectiveness and the individual cost of treatment should be 

considered in deciding which treatments or services to limit and in 

reaching decisions on individual patient needs. 

In some cases, the needs of a community for a range of treatments may 

outweigh the needs of an individual for a highly expensive treatment. 

Where an alternative, more cost effective solution can be found, it is 

appropriate for the LHB to consider this option. 

The LHB will consider each case on its individual merits and will therefore 

not set precedents either approving or refusing a particular treatment or 

service for an individual patient. 

iii) Patient choice/autonomy – patients should have a right to request 

treatments through their clinical advocate and have their case heard and 

considered 

The criteria and process for taking these decisions should be transparent 

and deemed fair. 

A separately constituted body to that making the initial decisions should 

receive and hear any disputes (see Sections 3 and 5 - Appeals Process). 

iv) Exceptionality – in cases where requests for funding are made for 

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treatments or services that have not been approved by national guidance 

such as NICE, The Cochrane Centre or Public Health Wales or the All Wales 

Medicines Strategy Group, in order for funding to be agreed then there must 

exist an unusual clinical factor about the patient that suggests that they are 

Significantly different to the general population suffering from their clinical 

condition 

Likely to gain significantly more benefit from the treatment or service than 

the general patient population with the clinical condition 

The requesting clinician should highlight any case of exceptionality to the 

LHB when making the funding application. 

The following definition has been recommended for use in Wales 1 : 

Central to consideration of individual cases is the concept of the case being 

exceptional. The definition of exception is 'an instance that does not follow a rule'. 

There cannot therefore be 'rules' to guide decisions on exceptions; rather such rules 

would constitute criteria (policy) to provide the service. 

1. In order for funding to be agreed there must be some unusual* clinical factor 

about the patient that suggests that they are 

i. Significantly different to the general population of patients with the 

condition in question 

ii. Likely to gain significantly more benefit from the intervention than 

might be expected from the average patient with the condition 

2. The fact that a treatment is likely to be efficacious for a patient is not, in itself, 

a basis for an exemption. 

3. If a patient's clinical condition matches the 'accepted indications' for a 

treatment that is not funded, their circumstances are not, by definition, 

exceptional. 

4. It is for the requesting clinician (or patient) to make the case for exceptional 

status. 

5. Social value judgments are rarely relevant to the consideration of exceptional 

status 

* The initial terminology was ‘unusual or unique’ but it is better to clearly differentiate 

unique from exceptional. 

1 Adapted from UK Specialized Services Public Health Network 

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Comment [R1]: ? add 

definition here

Section 3 - Funding Application Procedures 

3.1 The funding application process is in two stages. The core clinical structure of 

the LHB is based on Clinical Programme Groups (CPGs) and it is from within these 

groups that that the majority of funding applications will materialise. Recognising this, 

and the place of CPGs in being directly responsible for the delivery of care within 

their individual spheres of influence, applications in the first instance should be 

considered by the relevant CPG. Only applications considered and supported by the 

relevant CPG, and ‘signed off’ by the Chief of Staff, will be considered for funding by 

the LHB IPC Panel. 

3.2 Requests for funding a treatment/service may be made by a GP, hospital 

Consultant or other health professional (the referring clinician). The LHB will not 

normally consider the request for funding from a GP or a short term locum consultant 

(who may not be aware of local services or procedures) direct to a specialist in other 

NHS organisations with which the LHB does not already hold a contract for that 

particular service, unless this has the support of the relevant CPG. 

3.3 Self-referrals from patients will not be considered. Requests from patients and 

third parties (e.g. elected politicians) will be returned with the advice that the case 

should be discussed with the patient’s GP who should forward the request to a local 

secondary care consultant or other senior clinician with a view to discussion at CPG 

level. Referrals will not be accepted from a private clinician unless acting under 

contract with the NHS. 

3.4 Prior to considering an application for Individual Patient Commissioning 

funding, the CPG will require an NHS Consultant or GP to carry out a full assessment 

of the individual patient’s needs and decide whether the treatment or service being 

requested is the most appropriate for the patient. 

3.4.1 Before the request for funding can be considered by the CPG consideration 

will also need to be given to the clinical governance implications of the treatment – no 

funding request will be approved by the CPG where the clinical governance 

implications have not been addressed. 

Where a funding application is for a given drug evidence of approval from the BCUHB 

Drug & Therapeutics Committee (or sub committee at CPG level) will be required 

before support for funding is considered. 

3.5 The request for funding must be made on the agreed request form 

(please see Appendix 2) with information about the following completed: 

The patient’s medical history 

An outline of the proposed treatment/service including an indication of the 

likely duration of the treatment 

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Evidence of the clinical (and where appropriate) cost effectiveness of the 

treatment/service (such as from NICE guidance) and other sources of 

clinical evidence (such as from the Cochrane Centre) 

Other options for treatment/service that have been considered by the 

referring clinician and the reasons for exclusion of all alternatives 

considered 

Relevance to national guidelines (e.g. NICE, Royal Colleges, 

Professional bodies) if appropriate 

The prognosis of the patient 

A statement about why the patient is exceptional, where appropriate (i.e. 

where such treatment contradicts current NICE or AWMSG guidance) – 

see Section 2 above and Appendix 1. 

The full costs of the treatment/service for which funding approval is being 

sought. 

The proposed provider of the treatment/service and where possible, 

evidence of the quality of service provided. 

Where appropriate, whether HCW has already been approached for 

approval. 

D&T approval 

3.6 Incomplete forms will be returned to the referrer requesting additional 

information. It is beholden upon referrers to provide sufficient information to minimise 

this likelihood. 

3.7 The requests for funding will be submitted on the agreed request form to the 

Individual Patient Commissioning lead officer based within the CPG. Requests will 

be received and processed by the nominated CPG officer who will act as custodians 

for the requests. 

3.8 The IPC Panel checklist will be completed as part of this process (Appendix 3). 

3.9 The nominated lead officer will initially review the request to confirm that it is 

appropriate to be considered by the CPG as follows: 

The patient is confirmed to be under the care of the CPG and the request 

for treatment remains within the sphere of responsibility of that CPG. 

The patient is resident within the geographical responsibility of the LHB* 

All sections of the appropriate request form have been completed 

* as defined by the Ministerial letter ref EH/ML/014/09; Border PCTs are 

Shropshire County, West Cheshire, Herefordshire and Gloucestershire; From 

1st October 2009, the border LHB is defined as Betsi Cadwaladr University 

Local Health Board as a whole. 

3.10 All requests will be logged on the CPG Individual Patient Commissioning 

database which will have restricted access and will be maintained with due process 

and in accordance to strict Caldicott principles. 

3.11 Each CPG will be required to form it’s own Panel and/or process that 

considers each funding application in terms of clinical effectiveness and clinical 

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efficacy; in doing so the Chief of Staff of the CPG should ensure that the process is 

robust in terms of: 

• Caldicott principles 

• Informed clinical decision making in line with this document 

• Clinical governance and safety 

• Consistency 

• Transparency 

• Timeliness 

3.12 The CPG Panel or adopted process should ensure that a decision to support, 

or not support, the application is clearly recorded with the rationale behind the 

decision being clear. The process should ensure communication as to the outcome 

with the referring clinician at the earliest opportunity. 

3.13 The discussion regarding the submissions received by the CPG may include 

the referrer if the CPG deems this appropriate. 

3.14 All funding requests that have been deemed appropriate as above will be 

referred to the LHB Independent Commissioning Panel for further consideration by 

the CPG. 

On supporting a request the submission will be forwarded to the LHB IPC panel with 

a clear indication of that support and the signature of the CPG Chief of Staff 

CPG level Appeals 

3.15 In the event that the funding request has not been supported by the CPG, the 

referrer will be informed of this outcome as soon as possible. The referrer may wish 

to appeal the decision. In the event of an appeal, the referrer will be entitled to submit 

the application for funding to the LHB IPC Panel with clear notification on the 

application form that the submission does not have CPG support, with all relevant 

application information upon which the CPG would have considered their decision 

and with any comments that would respond to the CPG rejection. This appeal referral 

will require agreement from the Chief of Staff before being progressed. The LHB IPC 

Panel would still be entitled to discuss any supplementary information offered with the 

CPG concerned. 

The LHB IPC Panel 

3.16 It is the intention that BCULHB will have one IPC Panel which would be 

comprised of at least THREE individuals (one of whom must be a clinician) 

constituted by the following or their nominated deputy: 

Chief Executive 

Executive Medical Director and Director of Clinical Services 

Assistant Medical Director 

Executive Director of Nursing and Patients Services 

Executive Director of Primary, Community and Mental Health Services 

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Executive Director of Planning 

Executive Director of Finance 

Executive Director of Therapies & Health Science 

IPC Officer 

Associate Director of Performance Improvement and Delivery Support 

3.17 The final arrangements for one IPC Panel will be further considered and 

detailed in the revised IPC Standard Operating Procedure. 

3.18 A panel member must declare an interest if a patient for whom a funding 

request is made is known to the panel member. 

3.19 The LHB IPC Panel will only consider funding requests that have evidence of 

CPG support or those unless subject to appeal. The Panel may take advice in 

relation to all requests for treatment from within the relevant CPG, prior to the Panel 

making a recommendation. 

3.20 The LHB Panel may discuss funding considerations with other LHBs to try and 

ensure a consistent approach and the view of any relevant Clinical Networks may be 

sought. 

3.21 The LHB Panel will review all the information supplied on the agreed 

request form and will consider how appropriate the request is based on the 

information supplied. The Panel will consider each case on its individual merit and 

will base their recommendation on consideration of the facts presented to them in line 

with the agreed core principles outlined in Section 2. 

3.22 In reaching its recommendation on each individual case, the IPC Panel will 

consider: 

That all previous relevant criteria have been satisfied (see above) 

Whether there is a clear evidence base for clinical outcomes – this will be 

established by reference to NICE, Cochrane, Public Health Wales, 

AWMSG, SMC and SIGN and other authoritative sources of evidence; by 

asking relevant professionals within and outside the LHB and by 

consulting with Medical Directors of other LHBs or Public Health Wales. 

When an interpretation of evidence is being made, this should be 

validated using relevant experts such as LHB Medical Directors, or 

relevant health professionals within or outside the LHB. 

The effect of the proposed treatment or service on the quality of life, the 

social and psychological well being of the patient, symptoms relief and 

survival benefit. 

Any exceptionality that the individual patient may exhibit. 

3.23 This procedure cannot include a complete and exhaustive list of all factors to 

be considered, as each case will be considered on a case by case basis, and other 

case specific criteria may need to be considered on an individual by individual basis. 

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3.24 Any recommendation made by the IPC Panel does not reflect a policy or 

precedent made by the LHB. Rather it reflects a funding recommendation made on 

an individual patient after taking into account clinical evidence, specific aspects of the 

individual case and any exceptional circumstances. 

3.25 Each recommendation made by the IPC Panel will need to be considered by a 

BCULHB accredited clinician to determine that the recommendation: 

• Sets no apparent precedent for future IPC decisions; 

• Is congruent and consistent with other IPC decisions. 

3.26 Where the recommendation of the IPC Panel is incongruent or inconsistent 

with other IPC decisions, the clinician must be satisfied with the recommendation due 

to exceptional circumstances. (see Appendix 3). 

3.27 The recommendation of the IPC Panel will need to be ratified by one or more 

Executive Director with the intention that the decision will be conveyed by letter to the 

referring clinician within 5 working days of the Executive Director(s) reaching their 

decision, copied to the relevant Chief of Staff. In extremely urgent cases, the IPC 

Lead Officer may telephone the referring clinician after the decision has been made 

so that treatment may begin without undue delay. The notes of the telephone 

conversation should be faxed or e-mailed to the clinician for confirmation as soon as 

possible thereafter; information should also be shared with the appropriate Chief of 

Staff. The clinician should also be advised to send a copy of the Executive Directors 

decision to the patient and this suggestion will be included at the end of all IPC 

decision letters to the clinician. The IPC decision letter should include: 

The decision of the Executive Directors 

The reasons for the decision 

Any conditions imposed on the funding approval, including confirmation 

that the approved treatment will be within Welsh National waiting times 

standards for referral to treatment, and that the provider organisation will 

provide detail of individual patient waiting times on a monthly basis 

Any limits on the funding approval 

Any proposals for future care or discharge arrangements 

Any ongoing reporting or monitoring information required as a condition 

for the funding approval – these may need to be confirmed with the 

relevant CPG(s) 

Any other relevant information to support the decision taken 

Details of the appeals process where funding request is turned down (see 

section 5) 

The option to resubmit the request, should any further or additional 

relevant information become available. 

3.28 The Executive Medical Director or Executive Director of Planning (or their 

nominated deputies) must ensure that an overview of the case is maintained in 

collaboration with the referring clinician; that reports from the agreed process are 

reviewed and acted upon; and, in particular, ensure that, at an appropriate time, 

satisfactory discharge and aftercare arrangements are in place. In cases where there 

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is likely to be a need for intermediate, continuing health care and/or social care on 

discharge, a care manager/co-ordinator should be identified at the outset of 

treatment/service to ensure continuity of care. 

3.29 The LHB will maintain a confidential and secure database of all IPC decisions 

and the reasons for the decisions. 

Submitting a Funding Application to the LHB IPC Panel 

3.30 Having gained CPG support the request will be submitted on the completed 

form with the added indication of support from the CPG. The request will be 

submitted by the designated CPG nominated lead officer to the Individual Patient 

Commissioning lead officer based within the LHB. Requests will be received, date 

stamped and processed by the nominated LHB officer who will act as custodians for 

the requests. The IPC Panel checklist will be reviewed as part of this process. 

3.31 All requests will be logged on the LHB’s Individual Patient Commissioning 

database which will have restricted access and will be maintained with due process 

and in accordance to strict Caldicott principles. 

3.32 All funding requests that have been deemed appropriate as above will be 

considered by the LHB Independent Commissioning Panel that will meet every two 

weeks or when necessary. 

Section 4 - Child Protection Issues 

4.1 This process needs to be read in conjunction with the document ‘Best 

Practice Guidance for the Monitoring of Packages of Care for Children placed in and 

outside of Wales and funded by the Local Health Board’ (2006) 2 or and All Wales 

Child Protection Procedures (2008). This applies to all children and young people up 

to the age of 18 years. 

4.2 In addition to the procedures outlined in sections 1-3 above, all requests 

made to the LHB for funding of patients under the age of 18 must consider the 

following: 

If the request is deemed clinically appropriate, the application will be 

approved with the condition that evidence of compliance with the 

essential safeguards as outlined in the All Wales Child Protection 

Procedures is a requirement of funding. 

The Executive Medical Director or Executive Director of Nursing or 

person nominated by the Directors will request evidence of compliance 

with Child Protection and Health Status standards as identified in the 

‘Best Practice Guidance for the Monitoring of Packages of Care for 

Children placed in and outside of Wales and funded by the Local Health 

Board and All Wales Child Protection Procedures. 

2 NPHS Best Practice Guidance for the Monitoring of Packages of Care for Children placed in and 

outside of Wales and funded by the Local Health Board’ (2006) 

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Comment [R2]: Has this been 

run through All Wales Child 

Protection Service?

A copy of the best practice guidance document and the link to the Child 

Protection Procedures will be forwarded to the proposed placement/ 

current placement with a covering letter. 

Evidence provided should be recorded and further evidence of 

compliance requested if needed. 

Update information on placements used on a regular basis by the LHB 

should be requested and updated annually. 

Section 5 - Entitlement of Patients to Treatments Overseas 

5.1 Under current arrangements, patients are entitled to seek NHS funding for 

treatment overseas, whether via the E112 procedure or the Article 49 route. Refer to 

WHC 2007 044 for full details. Residents of North Wales are lawfully required to gain 

prior authorisation from the UHB to ensure that there is sufficient and permanent and 

access to high-quality hospital treatment, to control costs and prevent wastage of 

financial, technical and human resources. 

5.2 Requests for overseas treatments will follow the process outlined in Section 3 of 

this policy and needs to be referred to the IPC panel using the appropriate form. The 

following additional information is required: 

• How treatment centre was identified 

• Opinion on reasonable waiting time for patient based on their clinical 

findings 

• Why the patient cannot be offered treatment within this waiting time at the 

local service 

• Aftercare needs 

• Contribution to aftercare arrangements 

5.3 The criteria for UHB support are: 

• an objective clinical assessment of the patient’s clinical needs as set out in 

form HCDP 01 and considered by the IPC Panel; 

• where a waiting list exists, that the waiting time for treatment within the 

local service exceeds the time that it is clinically acceptable for the patient 

to wait at the time of the request on the basis of the clinical assessment; 

and 

• there is no other NHS provider who can offer treatment to the patient within 

the time deemed appropriate based on the clinical assessment. 

All 3 criteria must be met in order for an overseas treatment/procedure to be 

agreed. 

5.4 The UHB will only consider funding for treatment for the patient. Funding for 

carers travelling with the patient will not be considered. 

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5.5 The UHB will make contact with the suggested treatment centre in Europe to 

confirm; 

• The estimated cost of treatment 

• That the Clinician is willing to treat the patient 

• That the hospital supports the E112 system 

• Timescale for delivery of treatment 

• Aftercare arrangements. 

5.6 Should the request for funding be granted by the UHB, the referral to Europe 

will be made through the E112 process. The Department of Health is 

responsible for co-ordinating the information and arranging for the issue of the 

E112. In order to approve E112 applications, the Department of Health 

requires the following information: 

• Referral from a Consultant in the UK to a Clinician in Europe; 

• Letter of support from General Practitioner; 

• Written support of Local Health Board confirming that they will underwrite 

the cost of treatment; 

• Treatment commencement date and approximate duration of the treatment 

(E112 can only be issued for up to six months per episode of treatment) 

• Written confirmation of aftercare arrangements. 

5.7 The payment for treatment is processed through the Benefits Office in 

Newcastle. Local Health Boards underwrite the costs and they are deducted 

from any future allocations. 

Section 6 – LHB level Appeals Process 

6.1 The role of the appeals process is to ensure that due process was employed 

by the original Independent Patient Commissioning Panel and that the 

recommendation of that Panel and the decision of the Executive Director(s) involved 

were was reasonable based on the information available. 

6.2 Should the referring clinician or patient be unhappy with the decision taken by 

the LHB, they have the right to challenge the decision within 28 days of the letter 

being received by the clinician. Should a third party, other than the referrer, wish to 

appeal against the decision, written confirmation and authority must be obtained from 

the patient confirming that the third party is acting on the patient’s behalf. 

6.3 The referring clinician or patient/third party representative should write to the 

Chief Executive or Executive Medical Director, clearly detailing the reason/s for their 

dissatisfaction. Any such appeal should receive the support of the relevant CPG, 

through the Chief of Staff and evidence regarding this, be clear in any 

correspondence (there is not a requirement for the CPG Panel to be re-convened). 

The Chief of Staff should be in agreement with the appeal being made. 

16

6.4 On receipt of this correspondence, the Chief Executive or Executive Medical 

Director will then identify an appropriate alternative Director (not one involved in the 

original Panel decision) to act as an Investigating Officer and review the case to 

ensure that the LHB process has been fully implemented and followed. Should all 

LHB Directors have been involved in the original Panel decision the Chief Executive 

will identify an independent officer to review the case from outside the LHB. 

6.5 The Investigating Officer will convene an IPC Appeals Panel to consider the 

original decision based on the evidence available to it. It will consider : 

Was the original IPC Panel recommendation and Executive Director 

decision made in accordance with LHB procedures? 

Was due process followed? 

Was the decision legal? 

Was the decision made with consideration of all relevant factors 

available at the time? 

Was the decision reasonable and rational? 

Did the decision take due regard of the LHB’s legal and ethical 

framework? 

 

(See Section 2 for further details). 

6.6 The Investigating Officer will convene the IPC Appeals Panel as soon as is 

practical, especially for those cases where an early commencement of treatment 

would be needed. The membership of the group would be dictated by availability of 

appropriate LHB personnel but ideally should contain: 

The Investigating Officer (chair) 

Other LHB Director 

An external or non involved senior medical clinician Senior 

Senior planning representation 

Non-Executive Board member (lay representation) 

6.7 The members of the IPC Review Appeals must not have been involved in the 

original IPC Panel, and in order to ensure an adequate level of expertise, may well 

involve members from other LHBs. The Investigating Officer may well seek advice 

from appropriate sources and request the attendance of such individuals at the 

review Panel. The attendance of original IPC Panel members or Executive Directors 

might also be appropriate. 

6.8 The IPC Appeals Panel should not be asked to look at any new evidence that 

might have been submitted since the decision following the original IPC Panel. 

Should new evidence be available, the Appeals Panel may request the IPC Panel to 

reconsider their original recommendation in the light of the new evidence (see section 

3.20) 

6.9 The review of the case must be completed within 28 days of the receipt by the 

LHB of the request for review of the case. Should it be anticipated that the review will 

17

equire longer than 28 days, the LHB must inform the referring clinician/patient of an 

indication of the amount of time that will be required to complete the review. 

6.10 After due consideration, the IPC Review Panel may: 

Agree with and uphold the original decision 

Disagree with the original decision and request the Board Directors or 

IPC Panel to reconsider 

Partly agree with the original decision and make its own 

recommendations to the IPC Panel and Executive Directors 

5.11 Should the referring clinician/patient/third party representative remain 

dissatisfied following the review of their case, they will then be directed to the LHB 

complaints procedure. Such an approach should normally occur within 28 days of 

receipt of the appeals decision. 

Section 7 – Audit, Monitoring and Review Arrangements 

7.1 The Betsi Cadwaladr University Local Health Board will monitor compliance 

with the procedure on an ongoing basis by: 

Maintaining a confidential database of all IPC Panel activity (see 

sections 3.7, 3.9, 3.10 3.24 and 3.25) and regularly review this activity 

Monitoring of all costs incurred through the IPC procedure 

7.2 Providing a summary report to the LHB and CPG Boards on a six monthly basis 

18

Section 8 – Communications Strategy 

8.1 In order to ensure agreement and compliance with the IPC procedure, the LHB 

will disseminate the procedure to all local stakeholders – particularly local GPs, 

CPGs, Hospital Consultants and other Senior Clinicians. Copies of the procedure 

may also be sent to local Members of Parliament and National Assembly for Wales 

members if and when they seek to make an appeal on behalf of their constituents 

(see paragraph 3.3). 

19

C 

o 

m 

m 

u 

n 

i 

c 

a 

t 

i 

o 

n 

IPC Process – Algorithm 

Submission submitted 

by CPG but with clear 

indication that CPG 

does not support 

Not supported 

Clinician decides 

to 

appeal 

Consultant or GP or 

healthcare 

professional submits 

IPC funding request 

CPG IPC 

Panel 

Not Supported Supported 

LHB IPC Panel 

Appeals LHB IPC Panel 

Supported 

Funding identified 

20 

C 

o 

m 

m 

u 

n 

i 

c 

a 

t 

i 

o 

n

APPENDIX 1 

LOW EFFECTIVENESS PROCEDURES (LEPs) 

1. Introduction 

An evidence based approach uses the current best evidence in the decision making 

process, to ensure clinical effectiveness and maximum health gain from the 

resources available. The document provides a recommended list of treatments, 

procedures and therapies that should not be available or have limited availability 

across North Wales. The recommended course of action is provided, along with the 

current advice to support the recommendation. OPCS codes are also provided. For 

each procedure listed, Public Health Wales had provided the evidence upon which 

the LHB has based its decisions on whether to use or not. Pharmaceutical treatments 

are excluded, as there is a separate process for looking at these. The list is based on 

a rapid review of existing guidance from NICE and Public Health Wales, as well as a 

review of existing UK-wide policies. 

Procedures are split between those that should not be used in any circumstance and 

those that should not be used except under strict criteria. The latter are subdivided 

between lower volume (20/year) treatments, 

according to an analysis across North Wales undertaken in 2009 by Public Health 

Wales 1 . Where applicable the specific circumstances/strict criteria under which use 

can be considered by the LHB, are set out together with reference links to the 

available evidence. Procedures will be subject to the process outlined in Section 3 of 

the main policy. In addition, it will be necessary for procedures of higher volume to be 

subject to investigation and continuous review to ensure that the LHB position and 

interpretation of evidence continues to be consistent and appropriate. This will 

involve appropriate clinical engagement processes. NB. Procedures that are normally 

funded by Health Commission Wales and its successor organisation the Welsh 

Health Specialised Services Committee (WHSSC) have been shaded in grey. 

This does not purport to be a definitive list of LEPs. For example, NICE has published 

a list of Interventional Procedure Guidance available via the following weblink: 

http://www.nice.org.uk/Guidance/IP/Published, which should be consulted. It has also 

helped health professionals identify what additional measures should be put in place 

when implementing this guidance by adding an ‘arrangements’ column as follows: 

Type of Description 

arrangement 

Normal Apply normal consent, audit and clinical governance arrangements plus any 

additional recommendations, for example, on training, service delivery or data 

collection. 

Special Notify clinical governance leads, ensure patients understand the uncertainties 

referred to in the guidance, and audit and review clinical outcomes of all patients 

having the procedure plus any additional recommendations, for example, on training, 

service delivery or data collection. 

Other(see Guidance recommends a combination of normal or special arrangements. 

guidance) 

Research only Use only in the context of a formal research protocol. 

Do not use The procedure should not be used in the National Health Service. 

21

2. Procedures which should NOT be used by the NHS in any circumstance 

OPCS Condition Criteria Source of advice Remarks 

C40.4 

C44.1 

C44.2 

C46.1 

C46.7 

C47.6 

S33.1 

S33.2 

S33.3 

S33.8 

S33.9 

L78.8 

Y08.9 

OR 

L79.8 

Y08.9 

K23.4 

Y53.- 

Corneal implants 

for the correction 

of refractive 

error in the 

absence of other 

ocular pathology 

such as 

keratoconus. 

Correction of 

male pattern 

baldness 

Facial Atrophy – 

New-Fill 

Procedures 

Laparoscopic 

uterine nerve 

ablation (LUNA) 

for chronic pelvic 

pain 

Percutaneous 

laser 

revascularisation 

N/A NICE Interventional Procedure Guidance 

225 2 

http://guidance.nice.org.uk/IPG225/guidan 

ce/pdf/English 

N/A Health Commission Wales. 

Commissioning Criteria – Plastic Surgery. 

Procedures of Low Clinical Priority/ 

Procedures not usually available on the 

National Health Service 

http://wales.gov.uk/dhss/publications/healt 

hcommission/policies/plasticsurgery/plasti 

csurgerye.pdf 

N/A Health Commission Wales. 

Commissioning Criteria – Plastic Surgery. 

Procedures of Low Clinical Priority/ 

Procedures not usually available on the 

National Health Service 

http://wales.gov.uk/dhss/publications/healt 

hcommission/policies/plasticsurgery/plasti 

csurgerye.pdf 


234 

http://guidance.nice.org.uk/IPG234 


302 

http://www.nice.org.uk/nicemedia/pdf/IPG3 

Current evidence on the efficacy of corneal implants for 

the correction of refractive error shows limited and 

unpredictable benefit. In addition, there are concerns 

about the safety of the procedure for patients with 

refractive error which can be corrected by other means, 

such as spectacles, contact lenses, or laser refractive 

surgery. 

“Male pattern” baldness is a normal process for many 

men at whatever age it occurs. 

Facial atrophy is a loss of fat from the skin. Gel polymers 

such as New-Fill can be injected under the skin to recontour 

the depleted areas. 

The evidence on laparoscopic uterine nerve ablation 

(LUNA) for chronic pelvic pain suggests that it is not 

efficacious and therefore should not be used. 

Current evidence on percutaneous laser 

revascularisation (PLR) for refractory angina pectoris 

shows no efficacy and suggests that the procedure may


Y08.- for refractory 

angina pectoris 

C55.4 Scleral 

expansion 

surgery for 

presbyopia 

F32.8 Soft-palate 

implants for 

obstructive sleep 

apnoea 

Y53.2 Therapeutic use 

of ultrasound in 

hip and knee 

osteoarthritis 

K23.4 

Y08.- 

Transmyocardial 

laser 

revascularisation 

for refractory 

angina pectoris 

02Guidance.pdf pose unacceptable safety risks. 


70 

http://guidance.nice.org.uk/IPG70 


241 


41Guidance.pdf 

N/A Public Health Wales Evidence-Based 

Information 

http://www2.nphs.wales.nhs.uk:8080/healt 

hserviceqdtdocs.nsf/PublicPage?OpenPag 

e 


301 


01FullGuidance.pdf 

Current evidence on the safety and efficacy of scleral 

expansion surgery for presbyopia is very limited. There 

is no evidence of efficacy in the majority of patients. 

There are also concerns about the potential risks of the 

procedure. 

Current evidence on soft-palate implants for obstructive 

sleep apnoea (OSA) raises no major safety concerns, 

but there is inadequate evidence that the procedure is 

efficacious in the treatment of this potentially serious 

condition for which other treatments exist. 

The evidence suggests that the therapeutic use of 

ultrasound in hip and knee osteoarthritis provides no 

benefits beyond placebo, ultrasound or other 

electrotherapy agents in the treatment of hip and knee 

osteoarthritis. 

Current evidence on transmyocardial laser 

revascularisation (TMLR) for refractory angina pectoris 

shows no efficacy, based on objective measurements of 

myocardial function and survival. Current evidence on 

safety suggests that the procedure may pose 

unacceptable risks. 

23

3. LOWER VOLUME procedures which should NOT be used by the NHS EXCEPT under strict criteria 

OPCS Condition Criteria Source of Advice Remarks 

W71.4 

W85.3 

G28.4 

G30.1 

G30.2 

G30.2 

G30.4 

G30.8 

G30.9 

G71.6 

X85.1 

Autologus Chrondrocyte 

implantation for knee/ ankle 

problems caused by damaged 

articular cartilage 

Bariatric Surgery for morbid 

obesity 

Botulinum Toxin 

Should NOT be used EXCEPT in 

research studies that are designed to 

produce good quality information about 

the results of this procedure. 

See HCW policy for criteria 

Should NOT be used EXCEPT for the 

treatment of pathological conditions by 

appropriate specialists in cases of: 

• Frey’s syndrome. 

• Blepharospasm. 

• Cerebral Palsy. 

• Hyperhidrosis. 

NICE Technology 

Appraisal 89 

http://www.nice.org.uk/pa 

ge.aspx?o=TA089 


Evidence-Based 

Information 

http://www2.nphs.wales.n 

hs.uk:8080/healthservice 

qdtdocs.nsf/PublicPage? 

OpenPage 

HCW policy is currently 

being revised and will be 

issued shortly 

Health Commission 

Wales. Commissioning 

Criteria – Plastic Surgery. 

Procedures of Low 

Clinical Priority/ 

Procedures not usually 

available on the National 

Health Service 

http://wales.gov.uk/dhss/p 

ublications/healthcommis 

Evidence suggests that ACI has most 

commonly been used as a treatment for 

cartilage defects in the knee. There are 

few studies of its use in other joints. There 

are uncertainties about the potential 

adverse effects of the procedure and 

long-term effectiveness. 

Botulinum toxin is not available for the 

treatment of facial ageing or excessive 

wrinkles.


S02.1 

S02.2 

S02.8 

S02.9 

S03.1 

S03.2 

S03.3 

S03.8 

S03.9 

Body Contouring - ‘Tummy 

Tuck’ (Apronectomy or 

Abdominoplasty) 

Body Contouring – Other e.g. 

Buttock lift, Thigh lift, Arm lift 

(brachioplasty) 


following groups of patients who should 

have achieved a stable BMI between 18 

and 25Kg/m2 and be suffering from 

severe functional problems: 

• Those with scarring following trauma 

or previous abdominal surgery. 

• Those who are undergoing treatment 

for morbid obesity and have excessive 

abdominal skin folds. 

• Previously obese patients who have 

achieved significant weight loss and 

have maintained their weight loss for 

at least two years. 

• Where it is required as part of 

abdominal hernia correction or other 

abdominal wall surgery. 

Should NOT be USED except in 

exceptional circumstances. 

sion/policies/plasticsurger 

y/plasticsurgerye.pdf 




















Maintenance of a stable weight is 

important so that the risks of recurrent 

obesity are reduced. 

If there is severe and disabling 

psychological distress as a result of 

abdominal wall scarring, psychological 

therapy should be the initial treatment. 

Severe functional problems include: 

• Recurrent intertrigo beneath the skin 

fold. 

• Experiencing severe difficulties with 

daily living i.e. ambulatory restrictions. 

• Where previous trauma or surgical 

scarring (usually midline vertical, or 

multiple) leads to very poor appearance 

and results in disabling psychological 

distress or risk of infection. 

• Problems associated with poorly fitting 

stoma bags. 

The functional disturbance of skin excess 

in these sites tends to be less than that in 

excessive abdominal skin folds and so 

surgery is less likely to be indicated 

except for appearance. 

25


B31.1 

B27.5 

B31.2 

B30.1 

Breast - Male Reduction for 

Gynaecomastia 

Breast - Enlargement 

(Augmentation Mammoplasty) 

Should NOT be used EXCEPT if the 

patient is post pubertal and of normal 

BMI i.e. 18 - 25Kg/m2. 

Should NOT be used EXCEPT for 

women with an absence of breast tissue 

unilaterally or bilaterally, or in women 

with a significant degree of asymmetry of 

breast shape and / or volume (one cup 

size difference). Such situations may 

arise as a result of: 

• Previous mastectomy or excisional 

breast surgery. 

• Trauma to the breast during or after 

development. 

• Congenital amastia (total failure of 

breast development). 

• Endocrine abnormalities. 













Health Service. 

















There should be a pathway established to 

ensure that appropriate screening for 

endocrinological and drug related causes 

and to exclude testicular cancer through 

examination in Primary Care prior to 

consultation with a Plastic Surgeon. 

Liposuction may form part of the 

treatment plan for this condition. 

Patients who are offered breast 

augmentation in the NHS should be 

encouraged to participate in the U.K. 

national breast implant registration 

system and be fully counselled regarding 

the risks and natural history of breast 

implants. Patients should be provided with 

a copy of the DoH guidance booklet 

“Breast implants information for women 

considering breast implants”. (See 

website: www.doh.uk/bimplants). It is 

important that patients understand that 

they may not automatically be entitled to 

replacement of the implants in the future if 

26


B31.4 

B30.2 

B30.3 

B30.4 

Breast- Revision of 

Mammoplasty 

B35.6 Breast- Correction of Nipple 

Inversion 

• Developmental asymmetry. 

Patients must have a BMI within the 

range of 18Kg/m2 to 25 Kg/m2. 


NHS funded the original surgery. 

. 


functional reasons in a post-pubertal 

woman and if the inversion has not been 

corrected by correct use of a noninvasive 

suction device. 

























they do not meet the criteria for 

augmentation at that time. 

If revisional surgery is being carried out 

for implant failure, the decision to replace 

the implant(s) rather than simply remove 

them should be based upon the clinical 

need for replacement and whether the 

patient meets the criteria for 

augmentation at the time of revision 

Exclude malignancy as a cause - any 

recent nipple inversion might be 

suggestive of breast cancer and will 

require referral to the breast service under 

the rapid access two-week rule 

B31.3 Should NOT be used EXCEPT in severe Health Commission This is included as part of the treatment of 

27


Breast – Breast Lift 

(Mastopexy) 

G80.2 Capsule Endoscopy/ Pillcam 

A70.6 

X61.1 

X61.1 

X61.2 

X61.3 

X61.4 

X61.8 

X61.9 

Complementary Therapies 

and Alternative Medicine e.g. 

Acupuncture 

Alexander technique 

Aromatherapy 

Herbal medicine 

Hypnosis 

Homeopathy 

Massage 

Nutritional therapy 

Reflexology 

Other alternative therapies 

cases (Regnault Grade III) where the 

nipple lies below the infra-mammary fold 

and below the most projecting portion of 

the breast in the erect position. 


disease of the small bowel for: 

• Overt or transfusion dependant 

bleeding from GI tract, when source 

not identified on OGD/Colonoscopy 

• Crohns Disease in whom strictures are 

not suspected 

• Hereditary GI polyposis syndromes 

Complementary medicine/ alternative 

therapies are generally NOT used by the 

NHS. They are occasionally used as a 

treatment as part of a mainstream 

service care plan (e.g. as part of an 

integrated multidisciplinary approach to 

symptom control by a hospital based 

pain management team) and as such will 

be used as part of an existing contract. 

On existing available evidence the LHB 

will not support referral outside of the 

NHS for these services. Prior approval is 

required on a case by case basis for any 

requests outside the above criteria. The 












NICE Interventional 

Procedure Guidance 101 

http://guidance.nice.org.u 

k/IPG101 



Information 




OpenPage 

breast asymmetry and reduction (see 

previous) but not for purely 

cosmetic/aesthetic purposes such as 

post-lactation ptosis. 

The evidence suggests that there are 

large numbers of complementary and 

alternative therapies that have not been 

subject to the trials used to establish the 

effectiveness of conventional clinical 

treatments. The evidence base is 

developing and up to date evidence on 

complementary therapies and alternative 

treatments can be obtained from the 

Cochrane library and specialist evidence 

of NHS Library. 

28


N30.3 

F11.5 

F11.6 

Circumcision 

request for referral would need to be 

supported by evidence of the clinical 

effectiveness of the treatment and be to 

appropriately trained and qualified 

practitioners with recognised 

qualifications. 

Should NOT be used EXCEPT in the 

following cases: 

• Phimosis 

• Paraphmosis 

• Balantis and Balanoposthitis 

• Penile Cancer affecting the foreskin 

Dental implants Should NOT be used EXCEPT for 

patients who need post cancer 

reconstruction, major trauma with bone 

loss, anodontia, or on the advice of NHS 

specialists. 

The Faculty of Dental Surgery has 

produced guidance on the selection of 

patients for dental implant treatment 

within the NHS. These include three 

groups of patients for consideration: 

1. Endentulous in one or both jaws: 

• Severe denture intolerance (e.g. 

gagging, pain) 

• Prevention of severe alveolar bone 

loss 

2. Partially dentate 

• Preservation of remaining health teeth 

• Complete unilateral loss of teeth in 

one jaw 


Wales. Circumcision 

Commissioning Policy. 



sion/policies/circumcision/ 

circumcisione.pdf?lang=e 

n 



Information 




OpenPage 

Royal College of 

Surgeons. Guidelines for 

selecting appropriate 

patients to receive 

treatment with dental 

implants 

http://www.rcseng.ac.uk/f 

ds/clinical_guidelines 

Circumcision carried out for medical 

reasons should be rare and should only 

be carried out for urgent medical 

conditions. 

Circumcision for religious or cultural 

reasons should only be carried out and 

paid for on a private basis. 

The evidence suggests that dental 

implants have been shown to be a 

successful treatment. However, dental 

implant treatment should only be provided 

by appropriately trained dentists in 

accordance with General Dental 

guidance. 

29


D24.- Ear- Cochlear Implants 

3. Maxillofacial and cranial defects 

• Intraoral protheses e.g. considerable 

amounts of missing hard and soft 

tissue 

• Extraoral/cranial prostheses e.g. 

partial or total loss of ears, eyes or 

nose 


following: 

Paediatric cases that meet agreed 

audiological, physical and emotional 

criteria: 

• Bilateral sensorineural hearing loss of 

> 90 dBhl at 2 KHz and 4 KHz 

• Primary form of communication is 

spoken 

• Radiological examination has 

excluded retro – cochlear pathologies 

/cerebral defects 

• Patient should be fit for general 

anaesthesia 

• Referrals for accepted for both 

acquired and congenital hearing loss 

• Parental understanding and 

agreement to the long – term 

commitment of a cochlear implant 

Adult cases that meet agreed 

audiological, physical and emotional 

criteria: 

• Have severe - profound hearing loss 

bilaterally with an average hearing 

loss > 90 dBhl at 2 KHz and 4 KHz 


Wales. Cochlear Implants 

Commissioning Policy 



sion/policies/cochlear/coc 

hleare.pdf?lang=en 

Bilateral Cochlear Implants should not be 

used 

30


D03.3 

D03.1 

D03.2 

Ear - Correction of prominent 

ears (Pinnaplasty) 

Ear - Remodelling of lobe of 

external ear 

• Radiological examination has 

excluded retro – cochlear pathologies / 

cerebral defects 

• Patient should be fit for general 

anaesthesia and surgery 

• Have understanding and agreement to 

the long – term commitment of a 

cochlear implant 


following criteria: 

• The patient must be under the age of 

19 at the time of the referral. 

• Patients seeking pinnaplasty should 

be seen by a Plastic Surgeon and 

following assessment, if there is any 

concern, assessed by a psychologist. 


repair of totally split ear lobes as a result 

of direct trauma. 

Prior to surgical correction, patients 

should receive pre-operative advice to 

inform them of: 

• Likely success rates. 

• The risk of keloid and hypertrophic 

scarring in this site. 

• The risk of further trauma with re- 























Children under the age of five are usually 

oblivious and referrals may reflect 

concerns expressed by the parents rather 

than the child. 

Correction of split earlobes is not always 

successful and the earlobe is a site where 

poor scar formation is a recognised risk. 

31


S01.- 

X15.1 

X15.2 

X15.3 

X15.8 

X15.9 

Face - Face or Brow lift 

(Rhytidectomy) 

Gender Reassignment 

Surgery 

piercing of the ear lobule. sion/policies/plasticsurger 



treatment of: 

• Congenital facial abnormalities 

• Facial palsy (congenital or acquired 

paralysis) 

• As part of the treatment of specific 

conditions affecting the facial skin e.g. 

cutis laxa, pseudoxanthoma elasticum, 

neurofibromatosis 

• The correction of the consequences of 

trauma 

• To correct deformity following surgery 


patients who meet the following criteria: 

• The patient is at least 18 years; and 

• A minimum of 2 years full time 

residency in Wales; and 

• Has undergone a minimum of 12 

months continuous hormone therapy 

when recommended by a health 

professional and provided under the 

supervision of a physician; and 

• Has completed a period (normally a 

minimum of 24 months) of successful 

continuous real-life experience with no 

returning to their original gender; 

including one or more of the following; 

• For patients requiring a mastectomy, a 

minimum of 1 year successful 

continuous real-life experience will 














Wales. Gender Dysphoria 


http://wales.gov.uk/docs/d 

hss/policy/090424gender 

dysphoriaen.pdf 

These procedures will not be used for 

purely cosmetic reasons nor to treat the 

natural processes of ageing. However, 

there are a number of specific conditions 

for which these procedures may form part 

of the treatment to restore appearance 

and function. 

Written confirmation that the surgeon is 

satisfied that the patient meets the 

criteria, understands the ramifications and 

possible complications of surgery, and 

that the surgeon is of the view that the 

patient is likely to benefit from surgery is 

needed. 

Note: A bi-lateral mastectomy would 

normally be provided after 12 months on 

the pathway unless there are clinical or 

patient reasons not to proceed. 

Gender reassignment surgery is 

considered not medically necessary when 

one or more of the criteria have not been 

met. 

32


S60.6 

S60.7 

Hair - Hair Depilation/ 

Hirsuitism 

have been completed, with no 

returning to their original gender. 

• Maintain part or full-time employment; 

or 

• Function as a student in an academic 

setting; or 

• Function in a community-based 

volunteer; and 

• Acquire a legal gender-identity 

appropriate name change; and 

• Regular participation in psychotherapy 

throughout the real-life experience 

when recommended by a treating 

medical practitioner; and 

• Demonstrable progress in 

consolidating one’s gender identity 

role. 

• Demonstrable progress in dealing with 

work, family and interpersonal issues 

resulting in a significantly better state 

of mental health. This implies 

satisfactory control of problems such 

as sociopathy, substance misuse, 

psychosis, suicidality and self harm. 

• Demonstrable knowledge of the 

required length of hospitalisation, likely 

complications and post surgical 

rehabilitation 


patients who: 

• Have undergone reconstructive 

surgery leading to abnormally located 

hair-bearing skin. 

• Those with a proven underlying 







The method of depilation (hair removal) 

used should be diathermy, electrolysis 

performed by a registered electrologist, or 

laser centre. 

Where laser services are being developed 

33


C10.3 

S33.- 

S34.1 

S34.2 

S34.8 

S34.9 

Hair - Correction of hair loss 

(Alopecia) 

Hair - Transplantation 

endocrine disturbance resulting in 

Hirsutism (e.g. polycystic ovary 

syndrome). 

• Are undergoing treatment for pilonidal 

sinuses to reduce recurrence. 

• Hirsutism leading to significant 

psychological impairment. 

Should NOT be used EXCEPT when 

alopecia is a result of previous surgery or 

trauma, including burns. 


exceptional cases, such as 

reconstruction of the eyebrow following 

cancer or trauma. 






























reference to the available evidence base 

should be made. 

Should not be used, regardless of gender, 

for cosmetic reasons. 

34


X52.1 

Hyperbaric Oxygen Therapy 

(HBOT) for all indications 


following conditions: 

• Decompression Illness 

• Severe Carbon Monoxide poisoning 

that has not responded to 

conventional 

• Normobaric Oxygen therapy. 

C46.1 Laser therapy for short sight Should NOT be used EXCEPT if the 

patient has a biometry error following 

cataract surgery 

S62.1 

S62.2 

Liposuction 

Should NOT be used EXCEPT it is 

sometimes an adjunct to other surgical 

procedures. It should not be used simply 

to correct the distribution of fat. 

Liposuction for chronic lymphoedema 

should NOT be used EXCEPT with 



Wales. Hyperbaric 

oxygen therapy 




sion/policies/hyperbaric/h 

yperbarice.pdf?lang=en 



http://www.nice.org.uk/nic 

emedia/pdf/ip/IPG164pub 

licinfo.pdf 








HCW will only commission emergency 

HBOT. HCW will be notified by the 

hyperbaric chamber of emergency 

admission retrospectively and will not 

require prior approval. 

HBOT should not be used for: 

• Mild / Moderate Carbon Monoxide 

Poisoning responding to Normobaric 

Oxygen treatment; 

• Osteoradionecrosis 

• Non – healing diabetic wounds / ulcers 

Current evidence suggests that 

photorefractive (laser) surgery for the 

correction of refractive errors is safe and 

efficacious for use in appropriately 

selected patients. 

However, the safety and effectiveness of 

this procedure should be considered 

against the alternative methods of 

correction: spectacles and contact lenses. 

Liposuction may be useful for contouring 

areas of localised fat atrophy or 

pathological hypertrophy (e.g. multiple 

lipomatosis, lipodystrophies). 

35


U05.4 

U05.5 

U21.1 

Y98.2 

Z66.3 

Z66.4 

Z66.5 

Z66.8 

Z67.- 

Lower Back Pain (Nonspecific) 

– Plain X-rays of 

lumbar spine & MRI scans 

Lower Back Pain (Nonspecific) 

- General 

special arrangements for clinical 

governance, consent and audit or 

research. 


context of a referral for an opinion on 

spinal fusion or if one of the following 

diagnoses are suspected 

• Spinal malignancy 

• Infection 

• Fracture 

• Cauda Equina Syndrome 

• Ankylosing Spondylitis or another 

Inflammatory Disorder 

The following treatments should NOT be 

used for the early management of 

persistent non-specific low back pain: 

• SSRIs for treating pain 

• Injections of therapeutic substances 

into the back 

• Laser therapy 

• Interferential therapy 









emedia/pdf/IPG251Guida 

nce.pdf 

NICE Clinical Guideline 

88 


emedia/pdf/CG88NICEG 

uideline.pdf 


88 


emedia/pdf/CG88NICEG 

uideline.pdf 

36


C88.2 Photodynamic Therapy (PDT) 

for wet age-related macular 

degeneration 

• Therapeutic ultrasound 

• TENS 

• Lumbar supports 

• Traction 

The following referrals should NOT be 

offered for the early management of 

persistent non-specific low back pain: 

• Radiofrequency facet joint denervation 

• IDET 

• PIRFT 


individuals who have a confirmed 

diagnosis of classic with no occult 

subfoveal choroidal neovascularisation 

(CNV) (that is, whose lesions are 

composed of classic CNV with no 

evidence of an occult component) and 

best-corrected visual acuity 6/60 or 

better 


Appraisal 68 


k/TA68 

PDT is NOT recommended for the 

treatment of people with predominantly 

classic subfoveal CNV (that is, 50% or 

more of the entire area of the lesion is 

classic CNV but some occult CNV is 

present) associated with wet age related 

macular degeneration, except as part of 

research. 

37


S60.1 

S60.2 

S10.3 

S11.3 

S60.4 

Y06.4 

S06.5 

OR 

S06.9 

+ 

Y06.4 

S23.1 

S23.2 

S23.3 

S23.4 

Rhinophyma – Surgery or 

Laser treatment 

Scar revision 


severe cases or those that do not 

respond to medical treatment 


treatment of scars which interfere with 

function following burns or treatments for 

keloid or post surgical scarring 

























The first-line treatment of this disfiguring 

condition of the nasal skin is medical. 

38


S60.1 

S60.2 

Q29.1 

Q29.2 

Q29.8 

Q29.9 

Skin hypo-pigmentation The recommended NHS suitable 

treatment for hypo-pigmentation is 

cosmetic camouflage. Access to a 

qualified camouflage beautician should 

be available on the NHS for this and 

other skin conditions requiring 

camouflage. 

Skin “Resurfacing 

Techniques” – laser, 

dermabrasion & dermal peels 

Sterilisation – Reversal of 

(male and female) 

Should NOT be used EXCEPT for posttraumatic 

scarring (including postsurgical) 

OR severe acne scarring once 

the active disease is controlled. 


following circumstances: 

• If death of an existing child has 



























Information 

The evidence suggests that reversal of 

sterilisation for both females and males 

appear to be effective methods of 

restoring fertility. Those seeking 

39


Q37.1 

Q37.8 

Q37.9 

N17.1 

S09.2 

Tattoo removal 

occurred 

• Remarriage following death of spouse 

• Loss of unborn child when vasectomy 

has taken place during the pregnancy 



• Where the tattoo is the result of 

trauma, inflicted against the patient’s 

will (“rape tattoo”). 

• The patient was not Gillick competent, 

and therefore not responsible for their 

actions at the time of the tattooing. 

• Exceptions may also be made for 

tattoos inflicted under duress during 

adolescence or disturbed periods 

where it is considered that 

psychological rehabilitation, break up 

of family units or prolonged 

unemployment could be avoided, 

given the treatment opportunity. 

(Only considered in very exceptional 

circumstances where the tattoo 

causes marked limitations of 




OpenPage 


obstetricians and 

Gynaecologists. Male and 

female sterilisation. 

Guideline Summary. 

http://www.rcog.org.uk/wo 

mens-health/clinicalguidance/male-andfemale 

sterilisation 













sterilisation should be fully advised and 

counselled in accordance with Royal 

College of Obstetricians and 

Gynaecologists guidelines that the 

procedure is intended to be permanent. 

However, this procedure is not generally 

supported. Any provider carrying out 

sterilisation procedures should make it 

clear it will not be reversed on the NHS. 

40


S09.1 

S09.2 

C12.1 

C12.2 

C12.3 

psychosocial function). 

Vascular skin lesions NHS treatment is allowed for all vascular 

lesions except for small benign, acquired 

vascular lesions such as thread veins 

and spider naevi. 

Xanthelasma Palpebrum 

(Fatty deposits on the eyelids) 

Should NOT be used EXCEPT for larger 

lesions OR those that have not 

responded to these treatments AND if 

the lesion is disfiguring. 

























The planning of treatment of complex 

major vascular malformations is best 

carried out in a specialised multidisciplinary 

team setting. 

The following treatments should be 

considered for patients with xanthelasma: 

• Many Xanthelasma may be treated 

with topical trichloroacetic acid (TCA) 

or cryotherapy 

• Xanthelasma may be associated with 

abnormally high cholesterol levels and 

this should be tested for before referral 

to a specialist 

• Patients with xanthelasma should 

always have their lipid profile checked 

before referral to a specialist. 

41

4. HIGHER VOLUME procedures which should NOT be used by the NHS EXCEPT under strict criteria 


F12.1 

Q131 N34.2 

Q132 N34.4 

Apicectomy 

Assisted conception 

techniques – IVF, ICSI, Donor 

Insemination, MESA, TESE, 



• Presence of periradicular disease, with 

or without symptoms in a root filled 

tooth, where non surgical root canal 

re-treatment cannot be undertaken or 

has failed, or where conventional retreatment 

may be detrimental to the 

retention of the tooth 

• Presence of periradicular disease in a 

tooth where iatrogenic or 

developmental anomalies prevent non 

surgical root canal treatment being 

undertaken. 

• Where a biopsy of periradicular tissue 

is needed 

• Where visualisation of the periradicular 

tissues and tooth root is required when 

perforation, root crack or fracture is 

suspected 

• Where procedures are required that 

need either tooth sectioning or root 

amputation 

• Where it may not be expedient to 

undertake prolonged non-surgical root 

canal re-treatment because of patient 

considerations. 

See HCW Policy for criteria 



Information 




OpenPage 


Surgeons of England. 

Guidelines for surgical 

endodontics 

http://www.rcseng.ac.uk/f 

ds/clinical_guidelines/doc 

uments/surg_end_guideli 

ne.pdf 



The evidence suggests that the success 

rate of apical surgery on molar teeth is 

low. 

43


Q133 N34.5 

Q134 N34.6 

Q135 

Q136 

Q137 

Q138 

Q139 

Q383 

S06.5 

S06.9 

S09.1 

S09.2 

S11.1 

S11.2 

PESA. Egg sperm & gonadal 

tissue cryostorage, Other 

micro-manipulation 

techniques, Egg donation 

where no other treatment is 

available, IVF surrogacy 

Benign skin conditions – 

Removal of Lipomata 

As above Benign skin conditions – 

Removal of Viral warts 



• The lipoma (-ta) is / are symptomatic 

• There is functional impairment 

• The lump is rapidly growing or 

abnormally located (e.g. sub-fascial, 

sub-muscular) 

Painful, persistent or extensive warts 

(particularly in the immunosuppressed 

patient) may need specialist assessment, 

by a dermatologist. For a small 

proportion surgical removal (cryotherapy, 

cautery, laser or excision) may be 

appropriate. 

Policy Specialist Fertility 

Services 

http://wales.gov.uk/docs/ 

dhss/publications/091116 

commissioningpolicyspec 

ialisedfertilityen.doc 









http://wales.gov.uk/dhss/ 

publications/healthcommi 

ssion/policies/plasticsurg 

ery/plasticsurgerye.pdf 










Most viral warts will clear spontaneously 

or following application of topical 

treatments. 

44


As above Benign skin conditions – other 

e.g. benign pigmented moles, 

milia, skin tags, molluscum 

contagiosum, keratoses 

(basal cell papillomata), 

sebaceous cysts, 

corns/callous, 

dermatofibromas, comedones 

B31.1 

B31.4 

Breast - Female Breast 

Reduction (Reduction 

mammoplasty) 

Clinically benign skin lesions should not 

be removed on purely cosmetic grounds. 

This will include, amongst other 

conditions, skin tags and seborrhoeic 

keratoses (warts). 

Patients with moderate to large lesions 

that cause actual facial disfigurement 

may benefit from surgical excision. The 

risks of scarring must be balanced 

against the appearance of the lesion. 

Epidermoid or pillar cysts (commonly 

known as “Sebaceous cysts”) are always 

benign but some may become infected or 

be symptomatic. Some may require 

surgical excision particularly if large or 

located on the face or on a site where 

they are subjected to trauma. 

Should NOT be used EXCEPT if ALL the 

following circumstances are met: 

• The patient is suffering from neck 

ache, backache and/or severe 

intertrigo 

• The wearing of a professionally fitted 

brassiere has not relieved the 

symptoms 

• The patient has a body mass index 

(BMI) of 25Kg/m2 or less 



























Only in very exceptional circumstances 

will girls under the age of 16 be 

considered for this procedure. 

Following initial consideration of the 

referral by the Case Officer or equivalent, 

appropriate patients should ideally have 

an initial assessment prior to an 

appointment with a Consultant Plastic 

Surgeon to ensure that these criteria are 

met. (In the future consideration may be 

given to evaluating the benefits of having 

45


B30.- Breast -Prosthesis Removal 

or Replacement 

R17.- 

Caesarian Section (CS) - 

Elective 


NHS performed the original surgery and 

complications arise. 



• A term singleton breech (if external 

cephalic version is contraindicated or 

has failed) 

• A twin pregnancy with breech first twin 

• HIV (only if recommended by a HIV 

consultant) 

• Both HIV and hepatitis C (as above, 

there is no evidence that CS should be 

performed for hepatitis C alone) 

• Primary genital herpes in the third 

trimester (active genital herpes at the 

onset of labour) 

• Grade 3 and 4 placential praevia 

• Two previous caesarian sections or 















13 

http://www.nice.org.uk/pa 

ge.aspx?o=113190 

access to a trained bra fitter and 

introducing laser scanning of the thorax). 

Patients should be made aware that 

implant removal in the future might not be 

automatically followed by replacement of 

the implant. If revisional surgery is being 

carried out for implant failure, the decision 

to replace the implant(s) rather than 

simply remove them will be based upon 

the clinical need for replacement and 

whether the patient meets the policy for 

augmentation at the time of revision. 

When considering a CS, there should be 

a discussion on the benefits and risks of 

CS compared with vaginal birth specific to 

the woman and her pregnancy. Maternal 

request is not on its own an indication for 

CS and specific reasons for the request 

should be explored, discussed and 

recorded. When a woman requests a CS 

in the absence of an identifiable reason, 

the overall benefits and risks of CS 

compared with vaginal birth should be 

discussed and recorded. 

46


J18.- 

C13.1 

C13.2 

C13.3 

C13.4 

C13.8 

C13.9 

C15.1 

C15.2 

C12.1 

C12.2 

C12.3 

C12.4 

C12.5 

Cholecystectomy (for 

asymptomatic gall stones) 

Eyelid - Blepharoplasty 

more 

• Previous upper segment caesarean 

section or type unknown 

• Previous significant uterine 

perforation/ surgery breaching the 

cavity 


patients who are at increased risk of 

developing gallbladder carcinoma or 

gallstone complications 

Surgery on the upper eyelid should NOT 

be used EXCEPT to correct functional 

impairment (not purely for cosmetic 

reasons), as demonstrated by: 

• Impairment of visual fields in the 

relaxed, non-compensated state. 

• Clinical observation of poor eyelid 

function, discomfort e.g. headache 

worsening towards the end of the day 

and / or evidence of chronic 

compensation through elevation of the 

brow. 

Surgery on the lower eyelid should NOT 

be used EXCEPT for: 

• correction of ectropion or entropion 

• for the removal of lesions of the eyelid 



Information 




OpenPage 













There is insufficient evidence of clinical 

effectiveness of cholecystectomy (for 

asymptomatic gall stones). 

Excess skin in the upper eyelids can 

accumulate due to the ageing and is thus 

normal. Hooded lids causing significant 

functional impaired vision confirmed by an 

appropriate specialist can warrant surgical 

treatment. Impairment to visual field to be 

documented 

Excessive skin in the lower lid may cause 

“eye bags” but does not affect function of 

the eyelid or vision and therefore does not 

need correction. 

47


T59.- 

T60.- 

D15.1 

Ganglia – Surgical Removal 

Grommets - Drainage of 

middle ear in otitis media with 

effusion (OME) 

skin or lid margin. 


ganglion is very painful and restricts work 

and hobbies (subject to specialist 

surgical assessment and advice). 

Should NOT be used EXCEPT where: 

There has been a period of at least three 

months watchful waiting from the date of 

the first appointment with an audiologist 

or GP with special interest in ENT 

AND the child is placed on a waiting list 

for the procedure at the end of this 

period; 

AND OME persists after three months 

AND the child (who must be over three 

years of age) suffers from at least one of 

the following: 

• At least 3-5 recurrences of acute otitis 

media in a year 

• Evidence of delay in speech 

development 

• Educational or behavioural problems 

attributable to persistent hearing 

impairment, with a hearing loss of at 

least 25dB particularly in the lower 

tones (low frequency loss) 

• A significant second disability such as 

Downs syndrome 



Information 




OpenPage 

NICE clinical guideline 60 


emedia/pdf/CG60fullguid 

eline.pdf 

The evidence suggests that there is a 

high rate of spontaneous resolution for 

ganglia and that reassurance should be 

the first therapeutic intervention for most 

patients and all children 

Insertion of grommets is one of the five 

surgical procedures that the Department 

of Health monitors as indicators of excess 

surgical activity. 

48


H51.- 

H52.- 

Q10.3 

Q10.8 

Q10.9 

Q07.- 

Q08.- 

Haemorrhoidectomy 

Heavy Menstrual Bleeding - 

Dilation and curettage (D&C)/ 

Hysteroscopy 

Heavy Menstrual Bleeding - 

Hysterectomy 

Should NOT be used EXCEPT in cases 

of: 

• Recurrent haemorrhoids 

• Persistent bleeding 

• Failed conservative treatment 

D&C should NOT be used as a 

therapeutic treatment or as a diagnostic 

tool for heavy menstrual bleeding so will 

not receive prior approval for these 

conditions. 

Hysteroscopy should NOT be used 

EXCEPT when it is carried out: 

• As an investigation for structural and 

histological abnormalities where 

ultrasound has been used as the first 

line diagnostic tool and where the 

outcomes are inconclusive 

• When undertaking endometrial 

ablation 

Should NOT be used EXCEPT when: 

• Other treatment options have failed, 

are contraindicated or are declined by 

the woman 

• There is a wish for amenorrhoea 

• The woman (who has been fully 

informed) requests it 



Information 




OpenPage 


44 


k/CG44 


44 


k/CG44 

The evidence suggests that first and 

second degree haemorrhoids are 

classically treated with some form of nonsurgical 

ablative/ fixative intervention, 

third degree treated with rubber band 

ligation or haemorrhoidectomy, and fourth 

degree with haemorrhoidectomy. 

Dilation and curettage is one of the five 

surgical procedures that the Department 

of Health monitors as indicators of excess 

surgical activity. 

Hysterectomy is one of the five surgical 

procedures that the Department of Health 

monitors as indicators of excess surgical 

activity. 

49


E02.3 

E02.5 

E02.6 

E07.3 

F14.- 

F15.- 

F34.1 

F34.2 

F34.3 

F34.4 

F34.5 

F34.6 

F34.7 

Nose - Rhinoplasty 

Orthodontic treatments of 

essentially cosmetic nature 

Tonsillectomy – children & 

adults 

• The woman no longer wishes to retain 

her uterus and fertility 

Should NOT be used EXCEPT for: 

• Problems caused by obstruction of the 

nasal airway. 

• Objective nasal deformity caused by 

trauma. 

• Correction of complex congenital 

conditions e.g. cleft lip and palate. 

Priority will be based on those with high 

Index of Orthodontic Treatment Need 

Scores - 5,4 and 3 where a significant 

aesthetic component can be 

demonstrated and those with other major 

conditions e.g. craniofacial 

deformity/cancers 

Should NOT be used EXCEPT if patients 

meet ALL of the following criteria prior to 

referral: 

• Sore throat is due to tonsillitis 

• Five or more episodes of sore throat 

per year 













Health Evidence Bulletin 

Wales Oral Health 

http://hebw.cf.ac.uk/oralh 

ealth/index.html 


Paediatrics and Child 

Health. Guidelines for 

good practice. 

Management of acute 

and recurring sore throat 

and indications for 

Patients with isolated airway problems (in 

the absence of visible nasal deformity) 

may be referred initially to an Ear Nose 

and Throat (ENT) consultant for 

assessment and treatment. 

Evidence based on expert opinion 

suggests that orthodontic treatment 

should be directed at those individuals in 

which the greatest benefit can be 

achieved. 

Once a decision is made for 

tonsillectomy, this should be performed as 

soon as possible, to maximise the period 

of benefit before natural resolution of 

symptoms might occur 

Tonsillectomy is one of the five surgical 

50


F34.8 

F34.9 

L84.- 

L85.- 

L86.- 

L87.- 

L88.- 

F09.1. 

F09.3. 

Varicose Veins – 

asymptomatic & 

mild/moderate cases 

Wisdom teeth - Removal of 

asymptomatic 

• Symptoms for at least one year 

• Episodes of sore throat are disabling 

and prevent normal functioning 

A six-month period of watchful waiting is 

recommended prior to tonsillectomy to 

establish firmly the patterns of symptoms 

and allow the patient to consider fully the 

implications of the operation 



• ulcers/history of ulcers secondary to 

superficial venous disease 

• liposclerosis 

• varicose eczema 

• history of phlebitis 

Should NOT be used EXCEPT in cases 

where there is evidence of pathology 

tonsillectomy. 

http://www.rcpch.ac.uk/do 

c.aspx?id_Resource=171 

4 

Referral Advice National 

Institute for Clinical 

Excellence. 

http://www.nice.org.uk/m 

edia/A8F/DC/Referraladvi 

ce.pdf 

London Health 

Observatory 

http://www.lho.org.uk/co 

mmissioning/PCTClinical 

Exceptions.aspx 


Appraisal 1 


k/TA1 

London Health 

Observatory 

http://www.lho.org.uk/co 

mmissioning/PCTClinical 

procedures that the Department of Health 

monitors as indicators of excess surgical 

activity. 

Evidence from recent population surveys 

indicates very little relationship between 

symptoms and varicose veins – 

substantial numbers of patients without 

varicose veins have similar symptoms 

Most varicose veins require no treatment. 

The most common complaint about 

varicose veins is their appearance. When 

bleeding or ulceration occurs referral may 

be appropriate and of that number some 

may benefit from surgical intervention. 

Impacted wisdom teeth free from disease 

should not be operated on. 

51


Exceptions.aspx 

52

5. New, experimental and miscellaneous treatments which 

should NOT be used by the NHS EXCEPT under strict 

criteria 

New and experimental treatments will be judged on an individual basis. NICE will 

be the definitive guidance where available. However, it is recognised that many 

new treatments have not been subject to NICE. In such cases other recognised 

expert appraisals will be used as guidance including Cochrane, SIGN, SMC, the 

London Cancer Consortium and Public Health Wales Evidence-Based 

Information. The LHB will also be guided by research subject to internal and 

external evaluation of its merit through the New Technologies Oversight Process. 

6. Acknowledgements 

The authors would like to thank the following for their help and advice: 

Betsi Cadwaladr University Health Board – Brian Tehan, Medwyn Williams 

D&A Consultancy - Denise McCafferty 

Health Commission Wales - Hugo Van Woerden, Kamala Williams 

Health Solutions Wales – Sian Davies 

Public Health Wales - Paul Tromans, Nigel Monaghan, Norma Prosser, Mary 

Webb, Dinah Roberts, Sian King, Claire Jones, Siobhan Jones, Jo Charles, 

Ciaran Humphreys, Hugo Cosh, Hannah Lloyd, Ken Jones, Sandra Sandham 

7. Reference List 

1. Charles, J. and National Public Health Service for Wales. Interventions not 

normally funded. Analysis of North Wales Activity. April 2005- September 

2009. Bangor: NPHS, 2009 

2. Health Commission Wales. Commissioning Policy Specialist Fertility 

Services. Caerphilly: HCW, 2009. 

Available at: 

http://wales.gov.uk/docs/dhss/publications/091116commissioningpolicyspeci 

alisedfertilityen.doc 

3. Health Commission Wales. Gender Dysphoria Commissioning Policy. 

Caerphilly: HCW, 2009 

Available at: 

http://wales.gov.uk/docs/dhss/policy/090424genderdysphoriaen.pdf 

4. Health Commission Wales. Commissioning Criteria - Plastic Surgery. 

Procedures of Low Clinical Priority/ Procedures not usually available on the 

National Health Service. Caerphilly: HCW, 2010 

Available at: 

http://wales.gov.uk/dhss/publications/healthcommission/policies/plasticsurge 

ry/plasticsurgerye.pdf 

5. Health Commission Wales. Circumcision Commissioning Policy. Caerphilly: 

HCW, 2010 

Available at: 

http://wales.gov.uk/dhss/publications/healthcommission/policies/circumcisio 

n/circumcisione.pdf?lang=en 

BCULHB Draft IPC Procedure 53 18th February 

2010

6. Health Commission Wales. Cochlear Implants Commissioning Policy. 

Caerphilly: HCW, 2010 

Available at: 

http://wales.gov.uk/dhss/publications/healthcommission/policies/cochlear/co 

chleare.pdf?lang=en 

7. Health Commission Wales. Hyperbaric oxygen therapy Commissioning 

Policy. Caerphilly: HCW, 2010 

Available at: 

http://wales.gov.uk/dhss/publications/healthcommission/policies/hyperbaric/ 

hyperbarice.pdf?lang=en 

8. Health Evidence Bulletin Wales. Oral Health 1998. 

Available at: http://hebw.cf.ac.uk/oralhealth/index.html 

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Technology Appraisal 1. London: NICE, 2000 

Available at: http://guidance.nice.org.uk/TA1 

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appropriate referral from general to specialist services. London: NICE, 2001 

Available at: http://www.nice.org.uk/media/A8F/DC/Referraladvice.pdf 

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NICE, 2003 

Available at: http://guidance.nice.org.uk/TA68 

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presbyopia.NICE Interventional Procedure Guidance 70. London: NICE, 

2004 

Available at: http://guidance.nice.org.uk/IPG70 

13. National Institute for Clinical Excellence. Wireless capsule endoscopy for 

investigation of the small bowel. NICE Interventional Procedure Guidance 

101. London: NICE, 2004 

Available at: Available at: http://guidance.nice.org.uk/IPG101 

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Technology Appraisal 89. London: NICE, 2005 

Available at: http://www.nice.org.uk/page.aspx?o=TA089 

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the correction of refractive errors. NICE Interventional Procedure Guidance 

164 . London: NICE, 2006 

Available at: http://www.nice.org.uk/page.aspx?o=297508 


2010

16. National Institute Health and Clinical Excellence. Corneal implants for the 

correction of refractive error. NICE Interventional Procedure Guidance 225. 

London: NICE, 2007 

Available at: http://guidance.nice.org.uk/IPG225/guidance/pdf/English 

17. National Institute Health and Clinical Excellence. Laparoscopic uterine 

nerve ablation (LUNA) for chronic pelvic pain. NICE Interventional 

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Available at: http://guidance.nice.org.uk/IPG234 

18. National Institute Health and Clinical Excellence. Heavy menstrual bleeding. 

NICE Clinical Guideline 44. London: NICE, 2007 

Available at: http://guidance.nice.org.uk/CG44 

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programme NICE Clinical Guideline 13. London: NICE, 2008 

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children with otis media with effusion [OME] .NICE Clinical guideline 60. 


Available at: http://www.nice.org.uk/nicemedia/pdf/CG60fullguideline.pdf 

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revascularisation for refractory angina pectoris.NICE Interventional 


Available at: http://www.nice.org.uk/nicemedia/pdf/IPG301FullGuidance.pdf 

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Available at: http://www.nice.org.uk/nicemedia/pdf/IPG302Guidance.pdf 

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Clinical Guideline 88. London: NICE, 2009 

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obstructive sleep apnoea. NICE Interventional Procedure Guidance 241 



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lymphodema. NICE Interventional Procedure Guidance 251. London: NICE, 

2008 


26. Prosser N and National Public Health Service for Wales. Public health 

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2010

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9(1).doc 


evidence-based summary - Autologous chondrocyte implantation for ankle 

joints. Cardiff: NPHS, 2009 

Available at: 

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evidence-based summary - Haemorrhoidectomy. Cardiff: NPHS, 2009 

Available at: 


OpenPage 


evidence-based summary -Reversal of sterilisation. Cardiff: NPHS, 2009 

Available at: 


OpenPage 


evidence-based summary -Therapeutic use of Ultrasound in hip and knee 

osteoarthritis. Cardiff: NPHS, 2009 

Available at: 


OpenPage 


evidence-based summary –Complementary Therapies and Alternative 

Medicine Cardiff: NPHS, 2009 

Available at: 


OpenPage 


evidence-based summary – Dental Implants Cardiff: NPHS, 2009 

Available at: 


OpenPage 


evidence-based summary – Apicectomy Cardiff: NPHS, 2009 


2010

Available at: 


OpenPage 


evidence-based summary – Cholecystectomy for Asymptomatic Gall-Stones 

Cardiff: NPHS, 2009 

Available at: 


OpenPage 


evidence-based summary – Ganglia Cardiff: NPHS, 2009 

Available at: 


OpenPage 

36. Royal College of Obstetricians and Gynaecologists. Male and female 

sterilisation. Guideline Summary. 2004 

Available at: http://www.rcog.org.uk/womens-health/clinical-guidance/maleand-female-sterilisation 

37. Royal College of Paediatrics and Child Health. Guidelines for good practice. 

Management of acute and recurring sore throat and indications for 

tonsillectomy. London: RCPCH, 2000 

Available at: http://www.rcpch.ac.uk/doc.aspx?id_Resource=1714 

38. Royal College of Surgeons of England. Guidelines for surgical endodontics. 

London: RCS, 2001 

Available at: 

http://www.rcseng.ac.uk/fds/clinical_guidelines/documents/surg_end_guideli 

ne.pdf 

39. Royal College of Surgeons. Guidelines for selecting appropriate patients to 

receive treatment with dental implants: priorities for the NHS. London: RCS, 

1997 

Available at: http://www.rcseng.ac.uk/fds/clinical_guidelines 

8. Sources of Information 

Conwy Local Health Board. Procedures of Limited Clinical Effectiveness. Colwyn 

Bay: Conwy LHB; 2007. 

Conwy Local Health Board. Effective use of resources: Interventions of limited or 

unknown clinical value (draft). Conwy Local Health Board, 2007. Available at: 

http://www.wales.nhs.uk/sites3/Documents/271/Procedures%20of%20limited%20 

effectiveness.pdf [Accessed 24 th February 2010] 

Flintshire Local Health Board. Procedures of Limited Clinical Effectiveness. 

Mold: Flintshire LHB; 2007.Available at: 


2010

http://www.wales.nhs.uk/sites3/Documents/271/LHB%20Procedures%20of%20li 

mited%20effectiveness%202008.pdf [Accessed 24 th February 2010] 

NHS North Staffordshire. Low Priority Treatments – Commissioning Policy. Leek: 

NHS North Staffordshire; 2009. Available at: 

http://www.northstaffordshire.nhs.uk/documents/741.doc [Accessed 24 th 

February 2010] 

Leicester City Primary Care Trust. Low Priority Treatment Policy. Leicester: 

Leicester City PCT; 2008.Available at: 

http://www.leicestercity.nhs.uk/LowPriorityTreatmentPolicy3rdoctober2008_final_ 

-pdf.cmsdoc [Accessed 24 th February 2010] 

London Health Observatory. 2009. Commissioning - PCT clinical exceptions 

webpage [online].Available at: 

http://www.lho.org.uk/commissioning/PCTClinicalExceptions.aspx [Accessed 24 th 

February 2010] 

National Public Health Service. Treatments that should not be done either at all 

or unless strict criteria are adhered to. Cardiff: NPHS; 2010. 

Available at: 

http://www2.nphs.wales.nhs.uk:8080/healthserviceqdtdocs.nsf/($All)/C455EA251 

897B54F80257089004EE9B6/$File/NICElimitedeffectiverec.doc?OpenElement 

[Accessed 24 th February 2010] 

NHS Contract & Information Shared Services Unit. Draft Cheshire & Merseyside 

Prior Approval Scheme Incorporating Procedures of Lower Clinical Priority 

(PLCP), CISSU, 2010. 

NHS Contract & Information Shared Services Unit. Draft Cheshire & Merseyside 

Prior Approval Scheme Incorporating Procedures of Lower Clinical Priority 

(PLCP) Proposed Coding 

Available at: http://www.cissu.co.uk/index.html 

Powys Local Health Board Policy on Contract Exclusions (Procedures of Limited 

Clinical Effectiveness), 2007. 

Western Cheshire Primary Care Trust. Procedures of Limited Clinical Value. 

Chester: Western Cheshire PCT; 2009. 

Available at: 

http://www.westcheshirehealthconsortium.nhs.uk/document_uploads/Other_Docu 

ments/Procedures_Limited_Clinical_Value.doc [Accessed 24 th February 2010] 

Webb M and Mahmoud A. . Evidence-based advice to inform commissioning 

decision on “Interventions Not Normally Funded”. Cardiff: NPHS; 2007. 

West Sussex Primary Care Trust. Low Priority Procedures (LPPS) and Other 

Procedures with Restrictions (OPRS), West Sussex PCT, 2006. 

Wilde, M. Addendum to CISSU policy. CECPCT Supplementary policy for the 

commissioning of procedures and treatments that are not covered through the 

normal contracting process (Local addendum to Prior Approval Policy), Central 

and East Cheshire PCT, 2009 

APPENDIX 2 


2010

The Referring Clinician must consider and complete all the questions set out 

below and provide accurate, legible and clear information on each – the form 

should then be submitted to the CPG lead officer for individual funding requests. 

The CPG encourages referring clinicians to expand relevant sections where 

necessary to provide sufficient detail. 

This will enable the CPG IPC Panel to review the application for appropriateness 

in light of the benefits to the patient, equity of access for all patients and value for 

money and ensure adequate communication can take place with all those 

medical staff that have an interest in the patient’s treatment. 

Name of Patient: ________________________ Date of Birth: _________________ 

NHS Number: ________________________ Home Postcode:_______________ 

Name of Referrer (Applicant): ___________________ Job Title: _______________ 

Hospital or GP Practice: _________________________ Tel Contact: _______________ 

of above Applicant 

Questions Comments / Explanation (must be completed) 

1. What is the specific treatment 

/ procedure or appointment that 

the patient is being referred for? 

2a. Is this a one-off treatment, 

or will ongoing appointments / 

care / treatment be needed? 

2b. If this is ongoing care, 

please give a clear indication of 

the expected frequency and 

duration of care. 

3. What are your reasons for 

referring this patient? Please 

include a sufficient medical 

background, particularly 

where exceptionality may be a 

consideration. 

Please circle 

One-off 

Ongoing 


2010


4. Does this application have 

the support of the appropriate 

BCUHB (or CPG) Clinical 

Governance body (e.g. letter or 

notes from the CPG/BCUHB 

D&T committee) 

5. What is the clinical evidence 

to support the use of this 

treatment (please identify the 

sources of evidence based 

research) 

6. At what stage in 

NICE/AWMSG programmes is 

the requested treatment? Has it 

been appraised? If not, is it on 

their future agenda? Are there 

national guidelines from 

professional bodies, Royal 

Colleges or other home 

countries comparable bodies. 

7. If the request contradicts 

NICE or AWMSG guidance, 

explain why the patient is 

exceptional and this guidance 

does not apply (see Appendix 1) 

8. Please indicate any 

treatments the patient has 

already had and other options 

for treatment available that have 

already been considered. If 

these have been discounted, 

please explain why. 

9. Is the patient’s prognosis 

poor? If so, what information 

regarding prognosis has been 

given to the patient? 

Please 

Circle 

Yes 

No 


2010


10. Is the proposed treatment 

licensed for this indication? If 

necessary, please explain. 

11. What is the approximate 

cost of the treatment (per 

procedure/ per appointment) – 

This should include the planned 

number of treatments or 

procedures with an indicative 

total cost to the LHB. 

12. Which provider would you 

like the patient be referred to? 

Please justify your reasoning? 

Please indicate if this is an NHS 

body or a private organisation. 

13. Please identify the clinician 

under whose care the patient 

would be and their contact 

details (i.e. name, address, 

telephone, safe haven fax email) 

14. Where relevant, has Health 

Commission Wales already 

been approached to consider 

this request? 

Name of Patient’s GP: 

Practice: 

Name of Referring (Applicant) Clinician: 

Title: 

Address: 


2010 

Please Circle 

NHS 

Private 

Name of GP / Local Specialist who referred patient 

directly to applicant (for secondary or tertiary 

service applications as appropriate): 

Hospital of Local Specialist: 

Signature: 

Date


Identified CPG CPG support for application 

Yes No 

Signature 

Name Title 


2010

APPENDIX 3 

BCULHB LHB Individual Patient Commissioning (IPC) Panel Checklist 

Patients Initial XX Date of Birth xx-xx-xx NHS no XXXXXXXXXX 

Initial referral 

Date received Name of referrer Comments 

Supporting Evidence 

Permanent North Wales Resident or 

resident of border PCT but 

registered with a GP in North Wales 

Checked via Exeter 

Is this an NHS request? 

Fully Completed Application 

Proforma : 

Is this a prospective funding 

request? 

Does an LTA exist? 

Yes No Postcode: 

Yes No Comments where applicable: 

Yes No If incomplete or no proforma received: 

Date request made for completed proforma: 

Yes No 

Date completed proforma received: 

Initial: 

Comments where applicable: 


Is this a Health Commission Wales 

commissioned service? 


Initial Information logged onto Yes No Date: XX-XX-XX 

Database 

Initial:X.X. 

Case number assigned Yes No Case Number: XXX 

Initial:M.P. 

Advice sought and received from 

Public Health Wales or Medical 

Yes No Date and Outcome: 

Adviser 

Initial: 

Literature Review obtained and Yes No Date and Outcome: 

critiqued by Medical or Prescribing 

adviser 

Date of IPC Panel 

Initial: 

Panel Quorate? Yes No Comments where applicable: 

Medical History submitted & 

reviewed 



2010

Has the application been approved 

by the CPG, Drugs and Theraputics 

Committee or through other Internal 

Clinical Governance processes? 


Details of prognosis Yes No Comments where applicable: 

Evidence submitted by referring 

Applicant 


Evidence considered by Panel Yes No Comments where applicable: 

Relevance to National Guidelines Yes No Comments where applicable: 

Any further evidence submitted and 

considered, and by whom 

Case for Exceptionality submitted by 

Applicant 

Case for Exceptionality considered 

by Panel 

Other options for treatment 

submitted by 

Applicant 

Other options for treatment 

considered by Panel 

Yes No Comments where applicable 





Treatment supported by CPG Yes No Date and Outcome: 

Initial: 

Summary of Panel 

Recommendation 

Database updated Yes No Dates: XX-XX-XX 

Initial:X.X. 

Case completed and filed Yes No Dates: XX-XX-XX 

Initial:X.X 


2010

The following section should be completed by the approved BCU LHB accredited 

clinician (For routine funding decisions – this should be before relaying the Panel decision 

to the referring clinician (Applicant). For emergency and urgent funding decisions, this may 

need to be after relaying the Panel decision to referring clinician) 

Was this an Emergency / Urgent / Routine funding decision (please circle as appropriate)? 

Has a similar funding request been received by another IPC Panel within BCU LHB area? 

Yes / No 

Further information is needed prior to reaching a decision? Yes / No 

If yes, please comment 

………………………………………………………………………………………………………… 

………………………………………………………………………………………………………… 

Summary of BCU LHB accredited clinician’s view: 

In my opinion, after evaluating the recommendations of the above Panel, I consider: 

1. This funding recommendation is congruent and consistent with other BCU LHB 

Panel decisions Yes / No 

2. If No, this funding recommendation, although incongruent or inconsistent, is 

satisfactory due to the following exceptional circumstances considered by the 

Panel: 

……………………………………………………………………………………………………… 

……………………………………………………………………………………………………… 

……………………………………………………………………………………………………… 

……………………………………………………………………………………………………… 

……………………………………………………………………………………………………… 

……………………………………………………………………………………………………… 

Signed………………………………………….. Date: …………….. 

Print Name………………………………………………………………… 

Designation………………………………………………………… 


2010

Date of IPC Panel 

For LHB Use Only 

Panel Recommendation on 

Application 

Level of Funding approved (if 

recommended) 

Authorisation Number (if Approved) 

Name of Authorised Director 

Signature of Authorised Director 

Reasons for Panel decision 

Comments / Explanation (must be completed) 

Approved / Declined/ Deferred to Future Meeting/Further 

Information Requested 


2010

Betsi Cadwaladr University Local Health Board ... - Health in Wales

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