Information about Low Priority Procedures
The CCG has a fixed budget to commission healthcare and cannot routinely fund all treatments and procedures.
The CCG may decide that a treatment or procedure should not be routinely funded because of:
- Limited or no evidence of effectiveness
- It is considered a low priority for funding (e.g. some cosmetic surgery) compared to other treatments
- Treatment is subject to a clinical eligibility threshold (the patient has to satisfy certain criteria to receive treatment) such as contained in the national Evidence-based Intervention Policy published in 2018 by NHS England
Policies outlining any restrictions, thresholds for treatment and eligibility criteria for each procedure are available on the CCG website
Responsibilities for GPs
Be aware of the range of commissioning policies detailing the clinical restrictions to treatment applied by the CCG before referring any patients to Secondary Care.
Ensure that patients understand when there is likely to be no treatment offered on the NHS. Patients have the right to a second opinion from a consultant, but generally it is anticipated that a GP explanation of the system will suffice.
Ensure that referral is compliant with the relevant restrictive policy. Non-compliant referrals will be returned to the GP with the expectation that the GP will manage the patient.
Prior Approval Process
When referring GPs should include the patient history to enable funding decisions to be made in line with the policies.
To streamline referrals the CCG has implemented a process (via Referral Support Service – RSS) for a number of GP referrals to be approved before an appointment is made with a provider. This process will be used where the GP indicates that it is a procedure requiring Prior Approval.
The RSS team will provide the CCG’s decision following assessment of the referral by the Coventry and Warwickshire Individual Funding Request (IFR) team. Any referrals received by the RSS team which do not meet the referral criteria will returned to the GP for management of the patient in Primary Care.
Prior Approval Procedures and their Status
The following list provides a summary of the treatments or procedures where the CCG considers:
- There is limited or no evidence of its effectiveness.
- It is considered a low priority for funding (e.g. some cosmetic surgery) compared to other treatments.
- Treatment is subject to a clinical eligibility threshold (the patient has to satisfy certain criteria to receive treatment).
Prior approval required via RSS
- Carpal Tunnel Surgery *
- Dupuytrens Disease Surgery *
- Gallstone Surgery
- Ganglion Treatment (hand and wrist only) *
- Grommets / Myringotomy for Children *
- Hernia Repair
- Rhinoplasty / Septorhinoplasty / Septoplasty
- Tonsillectomy / Adenotonsillectomy*
- Trigger Finger Release*
- Varicose Vein Intervention*
- Primary Knee Replacement
- Primary Hip Replacement
- Hallux Valgus (Bunions)
- Arthroscopy of knee (therapeutic only)
Prior Approval Required
- Certain procedures as detailed in the Treatments Designed to improve Aesthetic Appearance
- Male Circumcision
- Continuous Positive Airway Pressure for Adults (CPAP)
- Hysterectomy for Menorrhagia
- Female Genital Prolapse
- Arthroscopic shoulder decompression subacromial pain*
Procedures that are Low Priority and NOT ROUTINELY FUNDED
- Adult snoring (no Obstructive Sleep Apnoea)*
- Arthroscopy for knee (diagnosis or treatment of osteoarthritis)*
- Back pain injections (no sciatica)*
- Dilation and Curettage for Menorrhagia Policy*
- Endoscopic Thoracic Sympathectomy (Facial Blushing and/or Sweating)
- Hyperhidrosis (excess sweating) of the palms or axillae
- Certain procedures as detailed in the Treatments Designed to Improve Aesthetic Appearance Policy
Procedures that are restricted and subject to patients meeting eligibility criteria
- Asymptomatic Carotid Artery Disease
*The acceptance criteria and funding restrictions for these procedures are in line with NHSE’s Evidence-based interventions Policy, November 2018.