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Mr James W Fairley BSc MBBS FRCS MS ( London )   Consultant ENT Surgeon

Mrs Sylvia A Fairley RGN RCNT Dip Nurs ( London )   Practice Manager

List of Low Priority Procedures in ENT

East Kent Hospitals University NHS Foundation Trust and Eastern and Coastal NHS PCT

Updated 20 November 2010

Can I get this treatment on the NHS? With public sector funding restricted, new rules came into force in 2010 regarding referrals for procedures considered to be of Low Priority. The following are not routinely funded, or have restrictions applied, for NHS Treatment in East Kent. Doctors in NHS Clinics have been given these policies to follow.

Contents

  1. Low Priority Procedures and Other Procedures with Restrictions
  2. Referrals
  3. Botulinum Toxin
  4. Facial Procedures:
    Pinnaplasty
    Repair of Lobe of external ear
    Rhinophyma
    Rhinoplasty / Septorhinoplasty
  5. Grommets
  6. Private Treatment Available on the NHS
  7. Refashioning of Scar
  8. Removal of Benign Skin Lesions
  9. Skin Grafts for Scars
  10. Viral Warts
  11. Tonsillectomies +/- adenoidectomies
  12. Bone Anchored Hearing Aids

1. Low Priority Procedures and Other Procedures with Restrictions

There is no blanket ban on these procedures.

There is a mechanism for dealing with those procedures not routinely funded, which is for the referring GP to complete an Individual Funding Application for the patient. If a hospital specialist doctor sees a patient in the out-patient clinic who would benefit from one of these procedures the GP must secure funding before listing the patient. The Trust will not be paid for unapproved procedures.

Patients who fulfil procedures with criteria (unless otherwise stated) do not need to be considered for individual funding. However, these procedures will be subject to audits to ensure adherence to the criteria.

2. Referrals

Referrals from the Referral Management Centre (RMC) will not be accepted as Authority to Treat. The RMC is not a clinical referral/triage service but an administrative service booking appointments for the community based services and cataracts.

GPs will be responsible for completing any IFR forms that may be required to give authority to treat

Referrals without or with an incomplete minimum data set, where one exists, will be returned to the referrer.

Referrals for LPPs not accompanied by an authorised Individual Funding Request form, will be returned to the referrer.

On occasions when the patient will need to be seen in order to make a decision as to the need for a LPPs, an outpatient attendance will be paid.

All complaints should be referred to the PCT Customer Services department in the first instance.

3. Botulinum toxin

This procedure will not be routinely funded for cosmetic reasons.

This policy is currently being reviewed by the Health Policy Support Unit. (HPSU)

4. Facial Procedures

For the purposes of these procedures a patient aged 16 years and under is consider a child/paediatric case. i.e. becoming an adult on their 17th Birthday.

Pinnaplasty (ENT Addendum to LPP – May 2010)

This procedure is not routinely funded for adults on cosmetic grounds. Available for children only (less than 16 years age), where the child, rather than parents alone, express concern.

Exceptional requests cannot be made on the basis that the request was not made before the child’s 16th birthday; other exceptional circumstances must be demonstrated.

Repair of Lobe of External Ear

This procedure is not routinely funded.

Surgery will be funded for the repair of completely split ear lobes as a result of direct trauma. Advice should be given regarding likely success rate, the risk of keloid and hypertrophic scarring at this site, the risks of further trauma with re-piercing of the ear lobule.

Rhinophyma

Treatment for this condition is not routinely funded.

The PCTs will consider funding if there is evidence of impairment of visual fields in the relaxed, non compensated state. An initial referral to an ophthalmologist is required to allow field testing so an assessment can be made.

Rhinoplasty / Septorhinoplasty (ENT Addendum to LPP – May 2010)

These procedures are not routinely funded.

Post traumatic rhinoplasty available.  Rhinoplasty for complex congenital conditions e.g. cleft lip and palate or airway problems available.  Straightforward cosmetic rhinoplasty is not available.

Prior Approval is required for complex or severe cases of the nasal septal deviation that are not post traumatic.

Septo-rhinoplasty will not be funded for aesthetic reasons only. An application for non-traumatic septorhinoplasty must demonstrate a clear clinical need for surgery and must be made by a Consultant.

A prior approval checklist should be completed and submitted to the relevant PCT.

5. Grommets (ENT Addendum to LPP – May 2010)

Adults

The PCTs will only fund grommets for adults in the following circumstances:

*Unilateral effusion requires urgent assessment and is detailed as criteria on the Kent & Medway Cancer Network Head and Neck Cancer referral form. Patients should be referred and treated in line with agreed rapid access pathways.

Any suspicion of malignancy at any stage of the pathway should be managed and treated appropriately

Children

Grommets for children under the age of 12 years should be undertaken in accordance with NICE Clinical Guidance 60 (Feb 2008) Surgical Management of the Otitis Media with Effusion in Children:

Primary Care: Assess features suggestive of OME and refer for formal assessment if necessary

Following formal assessment; children who will benefit from surgical intervention will be considered for surgery where:

Management of OME in children with Down’s syndrome

Hearing aids should normally be offered to children with Down’s syndrome and OME with hearing loss.

Management of OME in children with cleft palate

The PCT will also fund in the following instances:

Adenoidectomy for Otitis Media in children will not be routinely funded but combined with grommets will be considered in children who fulfil the criteria.

6. Private Treatment Available on the NHS

When clinicians retire from the NHS they may continue to practice privately. There are often patients who wish to continue seeing them, rather than see a new NHS clinician. The PCTs will not routinely fund private consultations in these circumstances.

7. Refashioning of Scar

This procedure is not routinely funded.

Patients will be eligible for treatment of scars that interfere with function, such as following burns, and may be eligible for treatment of keloid and post surgical scarring.

8. Removal of Benign Skin Lesions

This policy is currently being reviewed by the HPSU.

Available only where there is a pre-malignant potential or in line with strict criteria (assessment by Dermatologist) as follows:

Benign intradermal facial naevii or benign facial moles will not be considered.

PLEASE NOTE: The PCTs funds biopsy or excision of a lesion whenever there is concern that the lesion might have malignant potential. Such cases do not need approval by the PCT. The degree of suspicion of malignancy is a matter of clinical judgement by the referring clinician.

9. Skin Grafts for Scars

This procedure is not routinely funded.

The PCTs will fund this treatment for burns and as part of reconstruction following major trauma.

10. Viral Warts

Viral warts are usually of aesthetic significance only and surgical removal is not routinely funded by the PCTs. However, the PCTs will fund removal of viral warts in patients who are immunocompromised.

Most viral warts will clear spontaneously or following application of topical treatments so should normally be treated in primary care. Painful, persistent or extensive warts (particularly in the immuno-suppressed patient) may need specialist assessment by a GPwSI or a Dermatologist. For a small proportion surgical removal (cryotherapy, cautery, laser or excision) may be appropriate. However, treatment of viral warts on the eyelid is problematic and these should be referred for consideration of treatment.

There are no restrictions on treatment of genital warts.

11. Tonsillectomies +/- adenoidectomies

This procedure is not routinely funded except in children and adults who fulfil the criteria outlined below.

Patients may be considered for tonsillectomy if they meet all of the following criteria:

OR

The PCT will also consider patients with the following symptoms even if the patient does not meet all of the above criteria.

Once a decision is made for tonsillectomy, this should be performed as soon as possible, to maximize the period of benefit before natural resolution of symptoms might occur (without tonsillectomy).

Patients identified as having significant health risks but who don't meet the criteria should be considered via the Individual Funding Request (IFR) route as 'exceptional clinical circumstances'.

Any suspicion of malignancy requires urgent assessment and should be referred using the Kent & Medway Cancer Network Head and Neck Cancer referral form. Patients should be referred and treated in line with agreed rapid access pathways.

Bone Anchored Hearing Aids

This intervention is funded under the criteria stated in the relevant NICE guidance. Doctors in Kent and Medway NHS Hospitals should complete the following form to request funding for BAHA (Bone Anchored Hearing Aid) procedures.

Please complete the check list below to indicate which of the following criteria the patient meets
Does the patient have abnormalities of the middle, outer or external parts the ear or a chronic ear infection, which makes wearing a conventional hearing aid difficult or impossible ? Yes No
Does the patient have at least moderate permanent hearing loss in one or both ears (?41-60dB) that cannot be effectively treated by conventional audiological, medical or surgical interventions e.g. cannot be operated on and for which conventional hearing aids are not felt to suitable ? Please provide the relevant test results Yes No
Can the patient hear sounds well via bone conduction ? Yes No
Can the patient understand 60% or more of speech on a standard test (i.e word recognition scores), using bone conduction? Yes No
Is the patient able to keep the area around the fixture clean ? Yes No
Does the patient have more than 3mm of bone at the implant site ? Yes No
Is the patient older than 5 years ? Yes No
Does the patient have sufficient manual dexterity to remove or attach the external processor ? Yes No
Is the patient able to accept the abutment that protrudes from the side of the head ? Yes No