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Procedures of Limited Clinical Value (PoLCV) – MK CCG

Like all NHS organisations, Milton Keynes Clinical Commissioning Group (MKCCG) has limited resources and is responsible for using these in the most effective way. The CCG funds healthcare which is safe, effective and gives the best value in terms of health gains for the available funding.

There are some treatments which MKCCG does not routinely fund. These unfunded treatments are unlikely to bring health benefits and are sometimes known as ‘Procedures of Limited Clinical Value’.

A Procedure of Limited Clinical Value (PoLCV) is a procedure where the clinical effectiveness of that procedure is either absent or evidence shows weak efficacy. The CCG has developed a number of PoLCV policies based upon the evidence to evaluate a procedures clinical effectiveness. Each policy is categorised as either ‘Subject to Audit’, ‘Restricted’ or ‘Not Routinely Funded’. These are further defined as follows:

  • Subject to Audit – This is a policy with clinical thresholds for treatment, which need to be fully met in order for treatment. However, there are no Prior Approval requirements for this policy but a retrospective audit will be undertaken.
  • Restricted – This means the CCG will fund treatment if the patient meets the stated clinical threshold for care. Before the procedure is undertaken Prior Approval must be sought and obtained. Prior Approval means that a GP or Consultant must seek approval for an individual before treatment is carried out.
  • Not Routinely Funded means the CCG will not usually fund the treatment. A clinician may still request funding for that treatment but this will only be approved if an Individual Funding Request (IFR) proves exceptional clinical need and is approved by the IFR panel (Please refer to IFR Policy).

Policy development is an on-going process resulting from the publication of new evidence regarding clinical effectiveness. Policy reviews are undertaken in response fo NICE Guidance/Guidelines, health technology assessments etc.

New policies or reviews on existing policies will be published on the MKCCG website.

Exceptional cases must have exceptional clinical circumstances supported by robust clinical evidence. MKCCG has defined exceptionality as an unusual clinical factor (or factor affecting the clinical condition) about the patient that suggests that they are:

  • Significantly different to the general population of patients with the condition in question
  • Likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition

The fact that a treatment is likely to be effective for a patient is not, in itself, a basis for exceptionality. If a patient’s clinical condition matches the ‘accepted indicators’ for a treatment that is not funded, their circumstances are not, by definition, exceptional.

The Equality Act 2010 protects people against unfair treatment (discrimination) on the ground of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. The Equality Act defines ‘disability’ as a physical or mental impairment which has a substantial and long term adverse effect on your ability to carry out normal day to day activities.

Providers are reminded that under this Act they must make adequate and reasonable adjustment to services, which includes provision for interpreters, carers and for others from whom patients may require assistance, providing information and/or signage in an appropriate range of formats, media and languages. Providers shall ensure that service and customer care is delivered in an inclusive manner which respects the diversity of users. It is therefore unlikely that an application for additional funding for such adjustments will be successful.

The responsibility for adherence to these policies lies with the treating clinician and failure to adhere to these criteria may result in non-payment of the activity.

All patients being referred for non-urgent elective surgery who are smokers should be referred to smoking cessation services by the GP at the time of referral, and should be non-smokers at the time of surgery.  There is strong evidence of higher risks and worse surgical outcomes when a patient continues to smoke. The risks associated with smoking mean that it is not always safe for surgery to take place when a patient continues to smoke and, as a result, some surgeons will not carry out procedures until a patient is able to abstain from smoking.  For smokers who are unable to quit, the Royal College of Anaesthetists advises that smokers should give up smoking for at least several weeks before surgery and certainly not to smoke on the day of an operation.  Smokers are 38% more likely to die after surgery than non-smokers.

There is strong clinical evidence that obese patients undergoing surgery are at significantly higher risk of getting infections and suffering heart, kidney and lung problems than people who are a healthy weight.  They are also likely to have to spend more time in hospital recovering and their risk of dying as a result of surgery is higher compared to patients with a normal weight.  Overweight patients are strongly encouraged to lose weight BEFORE their operation and should consider delaying referral for non-urgent elective surgery; this is particularly applicable to patients who have a BMI over 40 or those with a BMI between 30 and 40 who have metabolic syndrome – a combination of diabetes, high blood pressure and obesity.  Patients should aim to reduce their weight by at least 10% over 9 months or to a BMI of less than 30.

There are a number of interventions which are the responsibility of NHS England as part of their Specialised Commissioning service.

Specialised sevices are those provided in relatively few hospitals, accessed by comparatively small numbers of patients but with catchment populations of usually more than one million. These services tend to be located in specialised hospital trusts that can recruit a team of staff with the appropriate expertise and enable them to develop their skills.

Further information on Specialised Commissioning can be found on:

https://www.england.nhs.uk/commissioning/spec-services/

https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2016/06/pss-manual-may16.pdf

Policies for Clinicians

MK CCG Policies

Please note that the Milton Keynes Joint Trusts Formulary Website cannot currently be accessed. If you have any queries about the formulary, please contact the CCG Pharmaceutical Advisers using [email protected]

The Primary Care process is available to download here.

The Secondary Care process is available to download here.

MKCCG POLCV policies apply to patients registered with a Milton Keynes GP Practice regardless of where their care is delivered. Where prior approval is required, Healthcare Providers should seek approval via the IFR team/Blueteq System.

The exception to this is Milton Keynes Hospital where an audit approach will apply to all policies, with the audit methodology determined by Milton Keynes Hospital and MKCCG.

“Cosmetic” surgery means procedures to improve appearance. It is also known as “aesthetic” surgery. Conditions resulting from major trauma or burns, which need reconstructive surgery, will usually be funded by the NHS.

Here you can access the Master Policy detailing The Provision of Cosmetic Treatments and Surgery.

The guidance lists procedures that are judged to be cosmetic and will not normally be funded by the NHS. The guidance applies to cosmetic surgery irrespective of the sub specialty of the surgeon concerned, including plastic surgery, ear nose and throat surgery, oral and maxillofacial surgery, dermatology, and other surgical specialties.

Procedure 

 

Category

                      

Individual policy attachments  

 

Abdominoplasty

 

Restricted Barthel Index of Activities of Daily Living

PA Form

Apronectomy (Tummy Tuck) Restricted Barthel Index of Activities of Daily Living

PA Form

Benign Skin Lesions Restricted PA Form

 

Blepharoplasty

Excess lower eyelid skin (as the sole procedure)

– Dermatochalasis (Excess upper eyelid skin)

Refer to policy PA Form

 

Botulinum Toxin (See also – Hyperhidrosis: management of hyperhidrosis policy) Refer to MK Formulary

 

https://www.formularymk.nhs.uk

 

Breast Surgery (Cosmetic)

– Breast Augmentation

– Mastopexy (Breast Lift)

– Nipple Surgery

– Prosthetic breast implants replacement

 

Not routinely funded

 

 

 

 

 

PA Form

 

Breast Surgery (Cosmetic)

– Breast Reduction (Female)

– Breast Reduction (Male)

Restricted
PA Form – Female
PA Form – Male
Brow Ptosis

– Brow Lift

 

Restricted

 

PA Form

 

Congenital Vascular Abnormalities

 

Not routinely funded
Ear Lobes (Repair of)

 

Not routinely funded
Gender Dysphoria

 

Refer to NHS England https://www.england.nhs.uk/wp-content/uploads/2013/10/int-gend-proto.pdf

 

Genital Cosmetic Surgery (Female)

 

– Labiaplasty

– Vaginoplasty

Not routinely funded
Hair

– Hair Loss

– Male pattern baldness

 

Not routinely funded
Hair

– Hair & Hirsutism (Abnormally Placed)

Restricted  PA Form
Liposuction Not routinely funded
Mandibular or Maxillary Osteotomy Restricted PA Form

 

Pinnaplasty (Bat or Prominent Ears) Restricted  PA Form
Prostrate Surgery

Redundant fat or skin removal

(from the arm, buttock or thigh)

 

Restricted Barthel Index of Activities of Daily Living

PA Form

Rhinoplasty Restricted PA Form

 

Rhytidectomy (Face Lift) Restricted
Scar Revision Restricted PA Form
Septoplasty Restricted PA Form
Septorhinoplasty Restricted PA Form
Skin Resurfacing (Dermabrasion) Not routinely funded
Tattoo Removal Not routinely funded
Telangiectasia’s (Thread Veins) Not routinely funded
Varicose Veins Restricted PA Form

Barthel Index of Activities of Daily Living

Venous Clinical Seveity Score

MKCCG has developed referral proformas for all policies categorised as Restricted – where Prior Approval is required. These electronic referral forms are also available on GP clinical system – SystmOne, once completed they need to be sent to [email protected]. Further policy details can be obtained by ‘clicking on’ the procedure name.

The referral proformas include all of the criteria which need to be met before a referral is made to secondary care and the proformas can be accessed by ‘clicking on’ the relevant policy PA Form. The requesting clinician will receive a letter/email giving the outcome of their Prior Approval submission. If approval is granted, the requesting clinician is responsible for sending the referral, along with proof of the approval to RMS. For those policies categorised as ‘Not Routinely Funded’ the referral requires approval from the Individual Funding Request (IFR) team.

The IFR form is available here and it is also available on GP clinical system – SystmOne.  This form is to be completed by the GP/Consultant when applying for funding for individual patients for clinical procedures which are categorised as Not Routinely Funded.

For more information, click here to view the NHS Milton Keynes CCG Policy for IFRs (November 2017) and IFR Guidance for Clinicians. Supporting information can be provided to evidence assessment within the form. Forms should be typed and signed, then send securely to [email protected]. The requesting clinician will receive a letter/email giving the outcome of their IFR submission. If approval is granted, the requesting clinician is responsible for sending the referral, along with proof of the approval to RMS.

Lenses – Filtered – Coloured

Procedure    Category    Individual policy attachments    
Adenoidectomy (as a standalone procedure) Not routinely funded
Adenoidectomy in conjunction with: – Grommet Insertion – Tonsillectomy Not routinely funded  PA Form Grommets insertion in adults Grommets insertion in children Tonsillectomy (Adults and Children)
 Ankyloglossia (Tongue Tie) – Division of Ankyloglossia Restricted  PA form
Aural Toilet (Microsuction) – Standalone in Secondary Care Subject to audit
Biological Mesh (Use of) – Abdominal Wall repair – Hernia repair Not routinely funded
Cataract Surgery NB: The Cataract Referral Form attached is only for use by optometrists who have gone through accreditation training to be able to assess and refer patients. Subject to audit Referral form
Chalazia or Chalazion Restricted PA Form
Cholecystectomy Subject to audit
Chronic Fatigue Syndrome (CFS) Not routinely funded
Circumcision (Male) Restricted PA Form
Complementary and Alternative Therapies Not routinely funded      
Divarication of Recti  Not routinely funded
Excess Skin (Removal)

  • Abdominoplasty
  • Apronectomy (Tummy Tuck)
  • Redundant fat or skin removal (e.g. buttock, thigh, arm, chin)

 

Restricted PA Form
Faecal Microbiota Transplant Restricted PA Form
Fertility Gamete Storage and Cryopreservation Restricted PA Form
Fertility – Donor Insemination (DI) – Intrauterine Insemination (IUI) Restricted Additional referral policy Referral Form 
Fertility – In Vitro Fertilisation (IVF) – Intracytoplasmic Sperm Injection (ICSI) within tertiary infertility services
Foot Drop of Central Origin – Use of Functional Electrical Stimulation Not routinely funded
Gastroparesis – gastro-electrical stimulation     Not routinely funded
Genital prolapse (female) Restricted PA Form
Grommets – Grommets insertion in adults Restricted PA Form
Grommets – Grommets insertion in children Restricted PA Form
Haemorrhoids Surgery Restricted PA Form
Hernias – Abdominal Hernias (adults) Restricted PA Form
Hernias – Asymptomatic Not routinely funded
Hernias – Repair (biological mesh) Not routinely funded
Hyperhidrosis – Endoscopic Thoracic Sympathectomy (ETS) – Iontophoresis Machine Not routinely funded
Hyperhidrosis – Laser Sweat Ablation or Retrodermal Curettage – Management of Hyperhidrosis with Botulinum Toxin A Restricted Laser Sweat Ablation or Retrodermal Curettage PA Form  Management of Hyperhidrosis with Botulinum Toxin A PA Form
IntraOcular Lens (IOLs) Implants Not routinely funded
Labiaplasty, Vaginoplasty and Hymenorrhaphy  Not routinely funded
Menorrhagia – Use of Ulipristal Acetate –  Endometrial Ablation –  Uterine Artery Embolisation –  Hysterectomy Subject to audit
Menorrhagia – dilation and curettage Not routinely funded
Myalgic Encephalomyelitis (ME) Not routinely funded  
  Mypoia (Short Sight Laser Surgery) Not routinely funded
Nasal Polyposis Restricted PA Form
Neurological Impairment – Lycra Dynamic Splinting (Children) Not routinely funded
Osteoporosis – Serum P1NP Measurement Not routinely funded
Rhinosinusitis Restricted PA Form
Sleep disorders – Treatment for Soft Palate Snoring Not routinely funded
Sleep disorders – Sleep apnoea in Adults Restricted PA Form STOP BANG Questionnaire Epworth Sleepiness Scale Questionnaire 
Sterilisation (Reversal of) – Sterilisation (Female) – Reversal of Vasectomy (Male) Not routinely funded
Surrogacy Not routinely funded
Tendinopathy – Autologous Blood and Platelet-Rich Plasma Injection Not routinely funded
Tonsillectomy (Adults and Children) Restricted PA Form
Ultrasound (Diagnostic) – Low-intensity Pulsed Ultrasound (LUPS) Not routinely funded

The Milton Keynes IMSK Service is a single point of access for musculoskeletal conditions. GPs should not refer outside of this pathway unless there are red flags that necessitate an urgent referral to secondary care. This service began on 1st April 2017. From this date, all patients over 16 years old with an MSK condition registered with a Milton Keynes GP should be referred to Ravenscroft for triage and where necessary treatment. Referrals should be sent to the RMS via E-Referral. Referrals will be triaged by specialist MSK Extended Scope Physiotherapists and where care is needed outside of the IMSK service, patients will be offered a choice of provider, where available. If prior approval is needed for a procedure, the IMSK service will undertake this assessment and complete the necessary forms. No prior approval form is required at the GP referral stage, however the forms remain here for secondary care clinicians needing to seek prior approval.

Procedure Category Individual policy attachments
Acupuncture – Low back pain – Osteoarthritis – LUTS in men – Induction of Labour   Not routinely funded
Bunions Restricted PA Form
Carpal Tunnel Syndrome – Carpal Tunnel Syndrome – Nerve Conduction Studies Restricted PA Form
Dupuytren’s Contracture Restricted PA Form
Femoro-acetabular Impingement Restrictied PA Form
Ganglion Restricted PA Form
Hip Arthroscopy Restricted PA Form
Hip replacement Restricted PA Form
Hip Resurfacing for Advanced Arthropathy Restricted PA Form
Injections – ultrasound guided corticosteroid injections Restricted PA Form
Injections for Therapeutic treatments – Epidural Injections for Lumbar Back Pain – Therapeutic Facet Joint Injections – Thermal Radiofrequency Denervation of Lumbar and Cervical Facet Joints Subject to audit
Joint  Replacement – simultaneous joint replacement – simultaneous hip joint replacement – simultaneous knee joint replacement – simultaneous shoulder joint replacement Not routinely funded
Knee Arthroscopy Restricted PA Form
Knee Replacement Restricted PA Form
Revision Surgery for Hip & Knee Replacement Restricted
Open MRI Restricted PA Form Open MRI is available at the following locations (Referral forms can be found through the providers web sites):

Pain Management – Inpatient Programmes for Adults with Chronic Pain Not routinely funded
Shoulder Arthroscopy Restricted PA Form
Shoulder Subacromial Decompression Restricted PA Form
Spinal Manipulation – Treatment of Chronic, Non-specific Low Back Pain Not routinely funded
  Spinal Surgery – Treatment of Chronic, Non-specific Low Back Pain Not routinely funded
Spinal Surgery – Spinal fusion – Disectomy   Not routinely funded
  Spinal Surgery   – Endoscopic laser spinal surgery – percutaneous intradiscal electrothermal therapies Not routinely funded
Trigger Finger   Restricted PA Form