Why does the CCG need a set of principles?
The CCG holds the keys and the purse strings for the majority of local health services. It is responsible for commissioning a wide range of clinical services, including secondary (hospital), community and mental health services for your area and for paying for those services, for and on behalf of, the local population. In some areas this also includes commissioning Primary care (GP services) alongside NHS England.
It’s guardianship of local NHS services needs to be done in an open, fair and transparent manner but in so doing must take into account fully and responsibly, the management of the limited resources at its disposal. A set of agreed principles is vital to help the CCG meet its duties and responsibilities and to guide the clinical decisions made by both the CCG and the full range of clinical Providers who deliver the healthcare it commissions.
Why does the CCG need a suite of clinical policies?
Having a set of agreed principles only goes so far in helping to make clinical decisions. Individual cases bring about specific issues that need greater detail and depth in order to allow equitable, practical and justifiable decisions to be made about the clinical treatment that should or should not be provided under the NHS.
Specific policies, based upon the set of principles, support the process of clinical decision making on a daily basis. Although still open to interpretation and judgment, policies provide a firm bedrock for decisions about services that can be recognised, understood and tested by all concerned; clinicians, commissioners, appeals panels, patients and other stakeholders.
CCGs are legally obliged to develop and publish the governance protocols it has established for decision making and the policies it has adopted to determine whether care and treatments are to be made available to the local population. As a significant proportion of clinical decisions fall within the remit of contracts or service level agreements between commissioner and providers (e.g. clinical commissioning groups and hospital trusts) the vast majority of clinical policies referred to in this document relate to decisions on procedures considered to be of low clinical value/priority.
What is meant by a governance framework?
As an organisation with responsibility for the expenditure of public money and the delivery of public services, a CCG must have a set of rules that governs what it does and how it does it. It must demonstrate integrity and solicitude in the decisions it makes. The governance framework, of which the principles and the clinical policies form a part, provides a legal and robust structure that both guides and protects the organisation and its members and gives meaning, reassurance and transparency to those (public, patients and others) who need to use and trust in its performance and decisions about their access to care and treatment.
Why review policies now?
It has always been a responsibility of CCGs and predecessor PCTs to review clinical policies on a regular basis. This is done to ensure that changes in best clinical/medical practice are taken into account, including National Guidance from NICE (National Institute for Health and Care Excellence) and other bodies. It also means updates as a result of new legislation or legal decisions can be made to existing policies. All policies have a review date, which is usually within two or three years of their adoption. Each CCG had policies due for review.
In addition, the individual funding request process (IFR) service provided by NHS Midlands and Lancashire Commissioning Support Unit applies the inherited policies of CCGs which were different from each other, some out of date and some up for review. This provided an ideal opportunity to review the policies across the CCGs, agree a common process for IFRs and increase the co-ordination of policies and services across Lancashire, making them more consistent and fair.
Which CCGs are involved?
All 8 CCGs in Lancashire are involved. These are:
- Morecambe Bay Clinical Commissioning Group
- Chorley and South Ribble Clinical Commissioning Group
- Greater Preston Clinical Commissioning Group
- West Lancashire Clinical Commissioning Group
- East Lancashire Clinical Commissioning Group
- Blackburn with Darwen Clinical Commissioning Group
- Fylde and Wyre Clinical Commissioning Group
- Blackpool Clinical Commissioning Group
Blackpool Clinical Commissioning Group run their own IFR process and are planning to review their policies in the near future but have joined in this review to help and inform this process and their own review.
Which policies are involved?
Each Clinical Commissioning Group in Lancashire has a range of clinical policies which varies from CCG to CCG dependent upon their local circumstances. It would be a long and arduous job to harmonise or replicate all these policies across all CCGs at the same time. A number of policies common to each CCG are being considered first. For example, each CCG had several policies relating to cosmetic procedures. It has been agreed to consolidate these into one Cosmetic Policy which replaces up to 8 previous policies. Other common policies include:
|Assisted Conception||Dilatation and Curettage/Hysteroscopy||Policy for the Commissioning of Services for People with Erectile Dysfunction|
|Treatment of Varicose Veins||Policy for Surgical Release of Carpal Tunnel Syndrome||Policy for the Commissioning of Testing for Malignant Hyperthermia|
|Reversal of Sterilisation in Males & Females||Hip Arthroscopy||Surgical Management of Otitis Media with Effusion using Grommets in Children (under 12 Yrs)|
|Complementary and Alternative Therapies||Planned Caesarean Section||Procedures of Limited Clinical Value (Better Care Better Value — Lumbar Spine procedures)|
|Endoscopic Procedures on the Knee Joint Cavity||Photorefractive (Laser) Surgery for the Correction of Refractive Error||Epilepsy Assessment — In-Patient assessment using video telemetry or residential care for young children and young people with severe epilepsy|
|Male Circumcision||Spinal Cord Stimulation||Inguinal, Umbilical and Femoral Hernias|
|Tonsillectomy||Surgical Release of Trigger Finger||Functional Electrical Stimulation for foot drop of central neurological origin|
|Excision of Uterus|
Other policies may be added to this list as the process continues.
What is the review process meant to achieve?
The main purpose of the review is to deliver the following outcomes for the CCGs, and through them, clinicians and patients.
- Review historical PCT policies to ensure a consistent and fair approach to reduce the ‘postcode’ lottery that can result from having different policies across a geographical area
- Develop a set of policies and principles against which to make these decisions
- Determine procedures that the CCG will not commission either routinely or at all – because the procedure does not satisfy principles under which the CCG commissions services or because particular criteria need to be met for the intervention to satisfy the principles. These need to be set out and demonstrated prior to approval of funding
- Update policies in accordance with National Guidelines and best clinical practice
- Develop collaborative policies across the 8 CCGs in Lancashire
What will this mean to patients?
The principles and policies under review guide the decisions made by CCGs about the care and treatment that will be made available to patients. This is in both what the CCG will commission and in what Providers of services will be asked and paid to deliver. This has a direct impact upon the services patients and the public can expect from their local NHS services. For the majority of patients this will mean little or no change to the services they access now as they will continue to be delivered as part of the commissioner/provider contract. However, for some services, such as those mentioned in the table above, there may well be a change in the service provided or that a service is no longer provided at all on the NHS due to its low clinical value, poor or unproven patient benefit and prioritisation of resources.
This will also have a direct impact upon decisions made for individual funding requests, both in terms of the referrals that GPs and their patients will make and in the decisions that IFR panels will make about those referrals.
By having one harmonised set of policies, all patients who may require a procedure will have to meet the same criteria, wherever they live in Lancashire. This ensures all patients are treated equally and that those who will benefit the most from the treatment will be able to receive it.
In cases where a patient will no longer be able to receive a treatment which they would previously been able to have, the patient will be supported by their GP to find alternative treatment which may be of greater benefit to them or in demonstrating they are an exception to the norm.
What impact will this have on individual funding requests?
Having the same or identical policies across CCGs will make the process for individual funding requests more streamlined, more efficient and reduce the likelihood of errors. There will be less confusion for both staff, patients and clinicians and the service will be more consistent, equitable and fair for the population across Lancashire as a whole.
What are procedures of limited clinical value?
Some routine treatments are now described as ‘Procedures of Limited Clinical Value’ (PLCV). These are procedures which national experts have suggested have only limited or temporary benefit, and which are not felt to be necessary to maintain good health. However, it may also include procedures which are deemed to be effective but which will only be so when specific criteria, conditions and circumstances are met. This means they need to be considered on a case by case basis and meet strict criteria before they can be funded by the NHS.
The clinical policies developed by the CCG are often concerned with procedures of limited clinical value and identify the criteria that must be met, the effectiveness of those procedures in dealing with the health problem or concern and circumstances when the treatments will be funded.
A clinical policy identifies the treatment available on the NHS in the area covered by the CCG and must be followed by all clinical staff within the area, including GPs. However, if the treatment is not normally funded or the criteria is not met but your GP feels there are exceptional circumstances in your case and you would benefit from this treatment, then your GP can support you in submitting an individual funding request (IFR) on the grounds of exceptionality to the policy (see additional points on IFRs elsewhere in the Q and A’s).
Is this about saving money?
No. Whilst we believe that harmonising policies across Lancashire will help us to deliver a more efficient service, our main priority is for these policies to be offered fairly and consistently across the area and to be clinically appropriate. However, this exercise is likely to result in some efficiency and/or operational savings for some of these policies/procedures, although there are also some areas where funding may increase.
Why do we need an Assisted Conception policy?
The NHS is primarily concerned with the treatment and care of patients who are ill or injured or who may have long-term physical and/or mental health needs that impact upon their general health and wellbeing. An inability to conceive or have children may or may not be clinical in origin but it is rarely linked to illness or injury and does not therefore, carry the same level of urgency and priority as some other NHS services. However, an inability to conceive can significantly impact upon the present and future general health and wellbeing of patients and, although of less a priority for NHS resources, there remain circumstances when it seems right to offer this service to patients. The assisted conception policy undertakes to determine under what circumstances and in which situations patients can expect to receive support from the NHS with conceiving and having children/a family.
I’ve seen reference to an IVF policy and an Assisted Conception Policy – what is the difference?
IVF (in vitro fertilisation) is a common and widely known method of assisting conception to take place, but it is not the only method available/used. IVF policies may concern IVF treatments only or they may be the name given erroneously to wider assisted conception policies. The new draft policy in Lancashire is rightly referred to as an ‘Assisted Conception’ policy as it relates to various methods of helping patients to conceive not just IVF.
I’ve seen the draft Assisted Conception Policy and it seems to be quite technical and complex – why?
The Assisted Conception Policy, as with all the clinical policies that CCGs adopt, are legal documents as well as guides to decision making on areas of low clinical value. As such the Assisted Conception Policy needs to be a robust document that stands up to both legal and clinical scrutiny. There are a significant number of medical/clinical techniques involved in assisted conception services and these need to be correctly referenced in terms of purpose and terminology. This can make the policy appear complex and less easy for the lay-person to understand.
I’ve requested or heard of requests for cosmetics procedures but not to a cosmetics policy – why is that?
All of the Clinical Commissioning Groups in Lancashire currently have a number of clinical policies that deal with cosmetic issues or with the patients’ appearance. In undertaking the process to review these cosmetics procedures the opportunity has been taken to consolidate these various policies, with a range of titles, into one overarching cosmetics policy. Procedures that you may have referred to previously will now come under the one policy but they will all have in common the fact that they are cosmetic and are concerned with the appearance of individuals.
Will someone with serious burns or other injuries come under the new draft cosmetics policy?
Cosmetic or what may be considered as cosmetic procedures in relation to trauma, such as serious burns and other accidents, and cancer treatments, remain unaffected by this policy. Although the policy identifies the general circumstances when these conditions may be treated, this policy is primarily concerned with treatments that relate to appearance only and not the restoration of appearance, or as much as this can be achieved, as part of the treatment of trauma, accidents and cancer.
Does the cosmetics policy cover issues relating to transgender?
Appearance changes requested or desired in order to align a patient’s appearance with that of their chosen gender are covered by the draft cosmetics policy. However, cosmetic procedures for people undergoing gender reassignment where those procedures fall within the commissioning remit of NHS England are not covered by this policy, which relates only to the responsibilities of Clinical Commissioning Groups. NHS England is responsible for the commissioning of gender reassignment services.
Which updated or revised clinical policies are included in the next public engagement process (referred to as Tranche 2)?
The group of policies subject to public engagement are as follows: the surgical treatment of Carpel Tunnel Syndrome; Tonsillectomy; the surgical release of Trigger Finger; Endoscopic Knee Procedures; Male Circumcision; and the funding of Insulin Pumps and Glucose Monitoring Devices for patients with (Type 1) diabetes.
What is Carpel Tunnel Syndrome?
Carpal tunnel syndrome (CTS) is a relatively common condition caused by compression of the median nerve within the carpal tunnel in the wrist. This gives rise to pain, numbness or tingling in the thumb, index and middle fingers. In severe cases it may cause nerve damage and weakness/wasting of the muscles of the hand, especially the thumb (Thenar wasting).Patients often report their symptoms are worse at night and may disturb sleep. The policy provides clinicians guidance on criteria for CCG commissioning on the surgical release of the carpal tunnel if all criteria is met.
In up to a third of cases carpal tunnel syndrome will disappear without treatment or with simple self-care. Non-surgical treatments, such as steroid injections or wrist splints are used to treat mild to moderate symptoms. Surgical release (decompression) of the carpal tunnel may be carried out if non-surgical approaches fail to relieve symptoms. Women are more likely than men to be affected by carpel tunnel syndrome and pregnant women can be more vulnerable. However, carpal tunnel syndrome in pregnancy often resolves within 12 weeks of delivery, but 50% of women have persisting symptoms at 1 year.
What changes have been made to the draft updated Carpel Tunnel policy?
There has been no change to the eligibility criteria in the policy. Only minor changes have been made to the policy document, where the section covering the principles has been expanded and explained more fully. Overall therefore, there is no change to the scope and nature of this policy or the treatment of patients.
Are tonsillectomies still allowed under the draft updated Tonsillectomy policy?
A tonsillectomy, the surgical procedure for the removal of the palatine tonsils, will continue to be commissioned by the CCG under the updated policy. Most of the eligibility criteria remain unchanged. The criteria stating that suspected malignancy would be funded without the need for prior approval has been removed.
Previous Tonsillectomy policies have also covered obstructive sleep apnoea, a relatively common condition where the walls of the throat relax and narrow during sleep, interrupting normal breathing. This may lead to regularly interrupted sleep, which can have a big impact on quality of life and increases the risk of developing certain conditions. The updated policy continues to commission the treatment of obstructive sleep apnoea by undertaking a tonsillectomy but the criteria has been expanded slightly, with a distinction now drawn between patients under 16 and patients over 16, the latter requiring advice from an expert in sleep apnoea.
Overall, there are modest changes to the criteria for tonsillectomy which will have little or no impact upon the service currently received by patients.
What is Trigger Finger?
Trigger finger is a condition that affects one or more of the hand’s tendons, making it difficult to bend the affected finger or thumb. If the tendon becomes swollen and inflamed it can ‘catch’, making it difficult to move the affected finger or thumb and can result in a clicking sensation. It usually affects the thumb, ring finger or little finger. One or more fingers can be affected, and the problem may develop in both hands. It’s more common in the right hand, which may be because most people are right-handed.
Symptoms of trigger finger can include pain at the base of the affected finger or thumb when you move it or press on it, and stiffness or clicking when you move the affected finger or thumb, particularly first thing in the morning.
If the condition gets worse, your finger may get stuck in a bent position and then suddenly pop straight. Eventually, it may not fully bend or straighten.
Trigger Finger can be treated with steroid injections but the policy is concerned with the surgical release of this condition.
What changes have been made to the draft updated Trigger Finger policy?
Under the updated policy the CCG will continue to commission the surgical release of Trigger Finger. There are still 3 criteria but these have been streamlined and the reference to comorbidities and a 4 month timescale removed. The 3 criteria are now very straight forward. A reference to the cost effective use of steroid injections has been removed as the policy is concerned with the use and effectiveness of surgical treatments only (the use of steroid injections for the treatment of trigger finger remains unaffected by this policy).
The minor amendments to the policy will have little or no impact upon the service currently received by patients.
What are Endoscopic Knee Procedures?
An endoscopic knee procedure, often referred to as knee arthroscopy, is a surgical technique whereby a small telescope is inserted into a joint to inspect, diagnose and treat problems inside the knee joint. Knee irrigation or washout involves flushing the joint with fluid, which is introduced through small incisions in the knee.
Endoscopic knee procedures are used to treat damaged ligaments or cartilage, loose bodies within the knee joint, grinding of the knee and what is known as plica syndrome, where a part of the knee (the plica) becomes inflamed or enlarged. Knee procedures are likely to affect older people and people with sport or other injuries as well as people with disabilities or with certain medical conditions.
What changes have been made to the draft policy on Endoscopic Knee Procedures?
The updated draft policy, although similar in scope to the previous policy, has undergone a few changes which will have an impact on some patients. The policy now specifies it is for people aged 16 and over. The treatment ‘endoscopic plica resection’, used to treat plica syndrome mentioned above, has been removed from the procedures that are funded. Treatment of ‘locked knee’ has now been stipulated and the ‘lateral release in patients with patellofemoral pain syndrome’ criteria (concerned with grinding of the knee) amended slightly, with the 6 month timescale no longer identified.
Does Male Circumcision still take place?
Male circumcision is the surgical procedure to remove all or part of the foreskin of the penis. It is a procedure that still takes place in order to prevent, diagnose and treat a medical condition such as infections and problems with the normal function of the foreskin, including during erections and intercourse. It is not and never has been available on the NHS for non-therapeutic purposes such as cultural, religious or cosmetic reasons
What changes have been made to the draft policy on Male Circumcision?
The draft updated policy continues to provide this procedure. It is broadly similar but identifies some additional circumstances/conditions when circumcision will be commissioned by the CCG, including traumatic injury, malignant lesions and congenital abnormalities, largely expanding on the ‘in the case of certain rare conditions identified by paediatric surgeons or urologists’ section of the original policy.
It is not anticipated that this will have any change to the service provided to patients.
Why was there no policy for insulin pumps and continuous glucose monitoring devices?
Although insulin pumps and continuous glucose monitoring devices have been around for a number of years they have now become more widely available and more accurate. They have also become more acceptable to both patients and clinicians. As a result it was felt appropriate that a policy, identifying the circumstances when the NHS would fund these devices and incorporating the latest clinical evidence and guidance, should be developed. This has led to the development of the new policy which, if adopted, would apply to all the CCGs in Lancashire.
Will diabetes insulin pumps and continuous glucose monitoring devices be available to anyone with diabetes?
No, the new policy identifies that these devices are only available for patients with Type 1 diabetes. In addition, various criteria must be met before the NHS in Lancashire will fund these devices for Type 1 diabetes. The purpose of these devices is to improve the control of diabetes in patients but many patients can satisfactorily control their diabetes using alternative means, without the need for these devices. Where this is the case funding would not normally be allowed.
Are insulin pumps and continuous glucose monitoring devices available for all ages?
Yes, the new policy permits the funding of these devices for all age groups, although different funding criteria apply to children below the age of 12, and different funding criteria also applies to children and young people between the ages of 12 and 18. If the various criteria are met the decision is still subject to patient choice (a patient may not want to use the device even if it is recommended) and to the patient complying with the use of the machine/device.