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

• Arthroscopy of knee (therapeutic only)
• Carpal Tunnel Surgery *
• Dupuytrens Disease Surgery *
• Ganglion Treatment (hand and wrist only) *
• Grommets / Myringotomy for Children *
• Grommets / Myringotomy for Adults
• Hallux Valgus (Bunions)
• Hernia Repair
• Primary Hip Replacement
• Primary Knee Replacement
• Rhinoplasty / Septorhinoplasty / Septoplasty
• Tonsillectomy / Adenotonsillectomy*
• Trigger Finger Release*
• Varicose Vein Intervention*

Please refer to the following GP Gateway pages on Hand & Wrist conditions

GP Gateway Hand & Wrist Pins & Needles

Gp Gateway Hand & Wrist Loss of Function

GP Gateway Hand & Wrist Swelling or Lump

GP Gateway Hand & Wrist Pain

 

Prior approval will still be required for interventions including Trigger Finger and Carpal Tunnel Syndrome

Please note that any references to “MSK Hub” should be currently interpreted as Community Physiotherapy pending future MSK Hub service development

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*
• Haemorrhoidectomy

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
• Labiaplasty
• 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
• Cataract

*The acceptance criteria and funding restrictions for these procedures are in line with NHSE’s Evidence-based interventions Policy, November 2018.

Coventry & Warwickshire Policies

CCG Policy Link	Link to Gateway Page & LPP Referral Forms	Patient Leaflet
Commissioning Policies Full List
Individual Funding Request (IFR) Policy
Adult Snoring Surgery (in absence of Obstructive Sleep Apnoea)	Snoring in Adults GP Gateway	IFR Snoring Leaflet
Aesthetic Policy – Treatments Procedures and Services Designed to Improve Appearance	Breast Surgery GP Gateway Benign Skin Lesions GP Gateway Chalazion GP Gateway	IFR Gynaecomastia Leaflet LPP Benign Skin Lesions Leaflet
Arthroscopic shoulder decompression subacromial pain	Shoulder Pain GP Gateway
Arthroscopy of the Knee Joint	Knee Arthroscopy GP Gateway
Assisted Conception	Fertility Problems GP Gateway
Carpal Tunnel Surgery	Carpal Tunnel Syndrome GP Gateway	LPP Carpal Tunnel  Leaflet
Cataract Surgery	Cataract Removal GP Gateway
Chalazion Removal	Chalazion GP Gateway
Chronic Fatigue Syndrome (CFS)
Complementary and alternative therapies	Complementary & Alternative Therapies GP Gateway
Dilation and Curettage for menorrhagia (D&C)	Dilatation & Curettage GP Gateway
Dupuytren’s Disease surgery	Dupuytrens Disease GP Gateway
Ganglion Treatment (Hand/Wrist)	Ganglion GP Gateway
Grommets and Myringotomy for Children	Myringotomy & Grommets GP Gateway
Grommets and Myringotomy for Adults	Grommets & Myringotomy (Adults) GP Gateway
Haemorrhoidectomy	Haemorrhoids & Haemorrhoidectomy GP Gateway
Hallux Valgus	Bunion – Hallux Valgus GP Gateway
Hysterectomy for Menorrhagia	Abnormal Uterine Bleeding GP Gateway
Injections for Non-specific Back Pain without Sciatica (previously Therapeutic Spinal Injections for Back Pain)	Spinal Injections GP Gateway	IFR Spinal Injections Leaflet
Primary Hip Replacement	Hip Pain (Adults) GP Gateway
Primary Knee Replacement	Knee Pain (Adults) GP Gateway
Rhinoplasty	Rhinoplasty Septorhinoplasty Septoplasty GP Gateway
Tonsillectomy & Adenotonsillectomy	Tonsillectomy & Adenotonsillectomy GP Gateway	LPP Tonsillectomy Leaflet
Trigger Finger Release Surgery	Trigger Finger GP Gateway
Varicose Veins	Varicose Veins GP Gateway