8 clinical policies - FAQs

What is Carpal 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 carpal 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 Carpal 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 three criteria but these have been streamlined and the reference to co-morbidities and a four month timescale removed. The three 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 six 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 and South Cumbria.

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 and South Cumbria 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.