TNRF2: Other procedures

Overview

Obstructive sleep apnoea/hypopnoea syndrome' (OSAHS) is a sleep-related breathing disorder characterised by recurrent episodes of complete or partial obstruction of the upper airway during sleep, causing apnoea (complete airflow obstruction with temporary absence or cessation of breathing) or hypopnoea (decreased airflow), respectively.

This is usually associated with symptoms such as excessive daytime sleepiness, irregular breathing at night, and cycles of transient arousal from sleep to restore normal airway muscle tone and airflow. It occurs due to excessive collapsing forces around the pharynx that exceed the decreased muscle tone during sleep.

Thresholds and eligibility

Take a sleep history and assess people for OSAHS if they have 2 or more of the following symptoms:

• Snoring
• Witnessed apnoeas
• Unrefreshing sleep
• Waking headaches
• Unexplained excessive sleepiness, tiredness, or fatigue
• Nocturia (waking from sleep to urinate)
• Choking during sleep
• Sleep fragmentation or insomnia
• Cognitive dysfunction or memory impairment

Note that there is a higher risk of OSAHS in people with certain conditions (see NICE NG202 1.1.2).

When assessing people with suspected OSAHS use the Epworth Sleepiness Scales in the preliminary assessment of sleepiness.

Consider using the STOP-Bang Questionnaire as well the Epworth Sleepiness Scale. DO NOT use the Epworth Sleepiness Scale alone to determine if a referral is needed, because not all people with OSAHS have excessive sleepiness.

As defined by British Snoring and Sleep Apnoea Association – using the Epworth Sleepiness Scale sleep apnoea is graded into:

• 0-10 - considered normal
• 11-14 - considered as mild day time sleepiness
• 15-18 - considered as moderate day time sleepiness
• 19-24 - considered as severe day time sleepiness

Consider diagnostic tests for assessing OSAHS including: home respiratory polygraph, home oximetry or polysomnography in accordance with NICE NG202 1.3. Sleep studies can determine the apnoea-hypopnoea index (AHI), the number of apnoeas and hypopnoeas per hour. The severity of OSAHS is determined using AHI values:

• Mild OSAHS: AHI of 5 or more to less than 15
• Moderate OSAHS: AHI of 15 or more to less than 30
• Severe OSAHS: AHI of 30 or more

Discuss appropriate lifestyle changes with all people diagnosed with any severity of OSAHS. Provide support and information of the beneficial effect on OSAHS of losing weight, stopping smoking, reducing alcohol intake, and improving sleep hygiene, tailored to the patient’s needs.

When referring people with suspected OSAHS to a local sleep specialist unit, include the following information in the referral letter to facilitate rapid assessment:

• Results of the person’s assessment scores
• How sleepiness affects the person
• Comorbidities
• Occupational risk
• Oxygen saturation and blood gas values, if available

Include details of excessive sleepiness during waking hours (rather than tiredness), whilst driving, working with machinery or whilst employed in hazardous or vigilant critical occupations. These patients will be fast tracked for investigation.

Continuous positive airway pressure (CPAP) for mild OSAHS;

For people with mild OSAHS who have symptoms that affect their quality of life and usual daytime activities, offer fixed-level CPAP:

• At the same time as lifestyle advice if they have any of the priority factors listed above
• If lifestyle advice alone has been unsuccessful or is considered inappropriate
• Offer telemonitoring with CPAP for up to 12 months
• Consider using telemonitoring beyond 12 months.
• Consider auto-CPAP as an alternative to fixed-level CPAP

If a person with mild OSAHS and symptoms that affect their usual daytime activities is unable to tolerate or declines CPAP, consider a customised or semi-customised mandibular advancement splint as an alternative to CPAP if they are aged 18 or over and have optimal dental and periodontal health.

Note that semi-customised mandibular advancement splints may be inappropriate for people with active periodontal disease or untreated dental decay, few or no teeth, generalised tonic-clonic seizures.

Continuous positive airway pressure (CPAP) for moderate and severe OSAHS;

CPAP is recommended as a treatment option for adults with moderate or severe symptomatic OSAHS:

• Offer fixed-level CPAP, in addition to lifestyle advice, to people with moderate or severe OSAHS
• Offer telemonitoring with CPAP for up to 12 months
• Consider using telemonitoring beyond 12 months.
• Consider auto-CPAP as an alternative to fixed-level CPAP

If a person with moderate or severe OSAHS is unable to tolerate or declines to try CPAP, consider a customised or semi-customised mandibular advancement splint as an alternative to CPAP if they are aged 18 or over and have optimal dental and periodontal health.

Note that semi-customised mandibular advancement splints may be inappropriate for people with active periodontal disease or untreated dental decay, few or no teeth, generalised tonic-clonic seizures.

Further treatment options for OSAHS;

Consider a positional modifier for people with mild or moderate positional OSAHS if other treatments are unsuitable or not tolerated. Note that positional modifiers are unlikely to be effective in severe OSAHS.

Surgery for OSAHS is not routinely funded;

Consider tonsillectomy for people with OSAHS who have large obstructive tonsils and a body mass index of less than 35 kg/m2. If all options involving lifestyle changes, CPAP, intra-oral devices have been tried and failed, despite medically supervised attempts, and in line with NICE NG202, consider referral for assessment for oropharyngeal surgery (uvulopalatopharyngoplasty, laser-assisted uvulopalatoplasty, soft palate implants, and radiofrequency ablation) in people with severe OSAHS. Surgical procedures for the treatment of this condition for people with severe OSAHS will only be funded if:

• A sleep clinic or respiratory consultant makes a recommendation for a surgical assessment of a patient with sleep apnoea.

AND

• The subsequent surgical assessment confirms the need for a surgical intervention to address the sleep apnoea.

Follow-up and monitor people with OSAHS in accordance with NICE NG202 1.9.

Support adherence to treatment for OSAHS in accordance with NICE NG202 1.10.

For more information go to:

Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s

Continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome

Snoring;

Snoring is a noise that occurs during sleep that can be caused by vibration of tissues of the throat and palate. It is very common and as many as one in four adult’s snore. As long as it is not complicated by periods of apnoea (temporarily stopping breathing) it is not usually harmful to health, but can be disruptive, especially to a person’s partner.

Surrey Heartlands ICB support the recommendations as laid out in the Academy of Medical Royal Colleges evidence-based interventions guidance: Snoring surgery (in the absence of obstructive sleep apnoea), and NICE IPG240: Soft-palate implants for simple snoring. 

Recommendation;

It is on the basis of limited clinical evidence of effectiveness, and the significant risks that patients could be exposed to, this procedure (snoring surgery, including soft-palate implants) should not be routinely commissioned in the management of simple snoring.

Alternative Treatments;

There are a number of alternatives to surgery that can improve the symptom of snoring and should be recommended where appropriate. 

These include:

• Weight loss
• Stopping smoking
• Changes in sleeping position
• Reducing alcohol intake
• Medical treatment of nasal congestion (rhinitis)
• Mouth splints (to move jaw forward when sleeping)

For more information visit:

Snoring surgery (in the absence of obstructive sleep apnoea)

Soft-palate implants for simple snoring

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment. 

However, if the patient does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

 

Overview

Removal and replacement of breast implants (that were originally provided by the NHS) is considered to be a cosmetic procedure, and will not be funded unless there is a medical need (due to rupture or severe capsular contraction – thickening of the tissue around the implant causing pain or discomfort).

Thresholds and eligibility 

Removal of implants will be considered, if at least one of the following criteria are met: 

• Rupture of silicone-filled implant 
• Implants complication by recurrent infections 
• Extrusion of implant through skin 
• Implants with Baker Class IV contracture 
• Implants with a contracture that interferes with mammography 
• Intrinsic breast disease 

NHS Surrey Heartlands do not replace breast implants for aesthetic reasons. 

Re-insertion of implants following removal:

• Where implants were originally funded by the NHS for non-cosmetic reasons (such as breast cancer or severe trauma) then replacements should be considered in line with the reason for the original funding for implants. 
• Where implants were originally funded solely for cosmetic reasons they will not be replaced. 

If implants are bilateral and one implant has to be removed for a sound clinical reason, it will not be replaced so the woman should be given the choice as to whether she wishes only one or both implants to be removed. 

Privately funded implants

Where implants have been previously funded privately and require removal for a sound clinical reason and this has occurred within 12 months of insertion, the applicant should in the first instance approach the private provider to correct the problem rather than pursuing NHS funding. 

Where cases fall outside of these criteria and there is a possibility that they may be considered either rare or exceptional or both, they can be considered through the usual IFR process. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Female breast reduction can help women whose breasts are causing problems like backache due to their size.

Reduction surgery involves removing excess fat, glandular tissue and skin from your breasts.

Thresholds and eligibility 

Breast reduction should only be considered an option for patients who fulfil all of the following criteria: 

• Documented and ongoing physical symptoms of back, neck and/or shoulder pain due to large breasts (plus documented evidence of treatment for pain). 
• Requires more than 500g tissue removed from each breast (to be assessed by surgeon*). 
• Body mass index (BMI) less than 26kg/m². 
• Non-smoker.

GPs should not refer patients into secondary care if they do not fulfil the above outlined criteria (with the exception of estimating the amount of tissue). This recommendation does not apply to patients undergoing breast reconstruction as part of treatment for breast cancer. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Gallstones are small stones, usually made of cholesterol, that form in the gallbladder. In most cases, they do not cause any symptoms and do not need to be treated.

If a gallstone becomes trapped in an opening (duct) inside the gallbladder, it can trigger a sudden, intense pain in your tummy. In these cases, keyhole surgery to remove the gallbladder may be recommended. This surgical procedure is called a Cholecystectomy.

Thresholds and eligibility 

Cholecystectomy will not be funded for asymptomatic gallstones. Where patients are asymptomatic, an IFR application is required.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Asymptomatic gallstone removal will require an IFR application.

Overview

Haemorrhoids, also known as piles, are swellings containing enlarged blood vessels that are found inside or around the bottom (the rectum and anus). 

If there is no improvement to your piles after home remedies, further treatment may be required, either by surgical treatment or surgery.

Thresholds and eligibility 

Often haemorrhoids (especially early-stage haemorrhoids) can be treated by simple measures such as eating more fibre and drinking more water. 

When conservative treatments are unsuccessful, many patients will respond to outpatient treatments in the form of rubber band ligation or perhaps injection. 

Surgical treatment should only be considered for those that do not respond to these non-operative measures or if the haemorrhoids are more severe, specifically: 

• Recurrent Grade 3 or 4 combined internal/external haemorrhoids with persistent pain or bleeding.
• Irreducible and large external haemorrhoids.

Surgery should be performed, according to patient choice and only in cases of: 

• Persistent Grade 1 or 2 haemorrhoids that have not improved with dietary changes, banding, or injection.
• Recurrent and symptomatic Grade 3 or 4 haemorrhoids and those with a symptomatic external component. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

An incisional hernia is a protrusion of tissue that forms at the site of a healing surgical scar. 

Incisional hernias can be treated by pushing any protruding intestine back into the abdomen and repairing the opening in the muscle wall.

Thresholds and eligibility 

Surgical treatment should only be offered when both of the following criteria are met (These criteria apply to adults only):

• Pain/discomfort interfering with activities of daily living.

AND

• Appropriate conservative management has been tried first, e.g., Weight reduction where appropriate.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

An inguinal hernia usually happens when fatty tissue or a part of your bowel, such as the intestine, pokes through into your groin at the top of your inner thigh. It pushes through a weak spot in the surrounding muscle wall (the abdominal wall) into an area called the inguinal canal.

Inguinal hernias can be repaired using surgery to push the bulge back into place and strengthen the weakness in the abdominal wall.

Thresholds and eligibility 

This procedure is not routinely funded for asymptomatic or mildly symptomatic inguinal hernias in adults. Patients should be referred for surgical assessment if they meet the following criteria which apply to adults only: 

• A history of incarceration of, or real difficulty reducing, the hernia. 

OR 

• An inguino-scrotal hernia.

OR 

• Increase in size month to month.

OR

• Pain or discomfort significantly interfering with activities of daily living.

OR 

• Work related issues e.g., of work/missed work/unable to work/on light duties due to hernia.

Patients with femoral hernias should be referred for consultation. 

All cases of suspected femoral hernia and groin hernias in women are routinely funded. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

An umbilical hernia appears as a painless lump in or near the belly button (navel). It may get bigger when laughing, coughing, crying or going to the toilet and may shrink when relaxing or lying down.

Umbilical hernias can be treated with surgery to push the bulge back into place and strengthen the weakness in the abdominal wall.

Thresholds and eligibility 

Surgical treatment should only be offered when one of the following criteria is met (These criteria apply to adults only): 

• Pain/discomfort interfering with activities of daily living.

OR 

• Increase in size month on month. 

OR 

• To avoid incarceration or strangulation of the bowel. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Excessive sweating (Hyperhidrosis) is common and can affect the whole body or just certain areas. Sometimes it gets better with age but there are things you can do and treatments that can help.

Thresholds and eligibility 

Botulinum toxin A (BTX-A) and endoscopic thoracic sympathectomy will be funded under the following circumstances.

Botulinum Toxin A for Axillary Hyperhidrosis clinical thresholds

• Patient has primary axillary hyperhidrosis which occurs without stimulus of heat or exercise, and which has no other underlying clinical cause such as secondary hyperhidrosis due to hyperthyroidism, menopause, medication, or amphetamines, etc.

AND

• The excessive axillary sweating has a significant impact on the patient’s personal/professional life i.e., Hyperhidrosis Disease Severity Scale (HDSS) 3 or 4.
  • HDSS Scoring
    • Mild - sweating is never noticeable and never interferes with daily activities
    • Moderate - sweating is tolerable but sometimes interferes with daily activities
    • Severe - sweating is barely tolerable and frequently interferes with daily activities
    • Severe - sweating is intolerable and always interferes with daily activities

OR

• The patient has complications due to axillary hyperhidrosis such as skin maceration with secondary skin infections

AND

• Patient has failed to respond to a six- month trial of topical aluminium chloride or extra strength antiperspirants (i.e., no change in HDSS score).

OR

• Patient is unable to tolerate topical aluminium chloride (e.g., causes a severe rash).

AND

• The patient is unresponsive or unable to tolerate oral anti-muscarinic as recommended treatment options by the Area Prescribing Committee:
  • Oxybutynin (off label for hyperhidrosis)
    • BLUE on recommendation by the specialist team:
      • Immediate release (IR) preferred choice antimuscarinic treatment option.
      • Modified release (MR) preparation may be used for patients with intolerable side effects to IR preparation.
    • All other oxybutynin formulations for hyperhidrosis
    • Non-formulary.
  • Propantheline (licensed for hyperhidrosis)
    • BLUE on recommendation from the specialist team 
    • Offered after oxybutynin if intolerable side effects or inefficacy to that treatment.
  • Glycopyrronium oral (off label for hyperhidrosis)
    • RED traffic light status
    • Treatment choice after oxybutynin and propantheline if they have not been tolerated or have not been effective.
    • More expensive than other treatment options in primary care, although significantly less costly in secondary care.

AND

• Patient does not have any contraindications to the use of Botox injections:
  • Pregnancy or breast feeding.
  • Previous allergy to botulinum toxin.
  • Muscle disorders or use of muscle relaxant therapy.
  • Coagulation disorders, on concurrent aspirin or anticoagulant therapy.
  • Previous surgery to the axilla.

BTX-A is unlicensed for the treatment of palmar, plantar, or craniofacial hyperhidrosis.  It is not routinely funded and would require application only via the IFR process by the treating clinician.

NHS Surrey Heartlands does not routinely fund iontophoresis for excessive sweating.

Primary care advice

Although primary care is not directly responsible for requesting prior approval, primary care needs to be aware of the detailed clinical criteria relating to this commissioning policy before referring the patient to the appropriate secondary care service.  Primary care treatment options can be found on the Surrey PAD > Antimuscarinics - Hyperhidrosis > Health topics A to Z > CKS > NICE

Endoscopic thoracic sympathectomy

Endoscopic Thoracic Sympathectomy surgery for severe palmar or axillary hyperhidrosis will only be funded when all routinely commissioned treatment options have failed.  In addition, the patient must be fully informed of the risks, benefits, side effects of the procedure and the characteristics of a patient likely to experience better outcomes.

Routinely commissioned treatment options include:

• Lifestyle interventions
• Aluminium chloride 
• Oral antimuscarinic (see treatment options in previous section)
• Botulinum toxin A (see criteria in previous section)
• Local surgery (only for axillary hyperhidrosis)
• Iontophoresis is not currently routinely funded due to lack of high-quality evidence on its long-term efficacy.  Patients who wish to use Iontophoresis will need to purchase the required equipment privately.

Patients should be informed of the risks of serious complications associated with Endoscopic Thoracic Sympathectomy, such as hyperhidrosis elsewhere on the body in around 50% of patients, failure to reduce hyperhidrosis and some patients regret having had the procedure (especially because of subsequent and persistent hyperhidrosis elsewhere).

Funding for endoscopic thoracic sympathectomy for craniofacial hyperhidrosis will only be available when it coexists with facial blushing.

NHS Surrey Heartlands does not routinely fund endoscopic thoracic sympathectomy for plantar hyperhidrosis due to limited evidence on effectiveness.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

The ketogenic diet is a high-fat, adequate-protein, low-carbohydrate dietary therapy that in conventional medicine is used mainly to treat hard-to-control epilepsy in children. The diet forces the body to burn fats rather than carbohydrates.

Thresholds and eligibility 

Referrals will only be funded for children up to the age of 18 years with:

• Epilepsy whose seizures have not responded to appropriate AEDs (Refractory epilepsy).

OR

• Glucose 1 transporter deficiency.

OR

• Pyruvate dehydrogenase deficiency.

Refractory epilepsy is defined as a failure of adequate trials of two tolerated and appropriately chosen and used anti-epileptic drugs schedules.

Children with refractory epilepsy who are candidates for surgery may not be eligible for the diet. 

NHS Surrey Heartlands recommend that the classical ketogenic diet (CKD) is used as first line for those who might be considered. However, other variants of the diet may be used if this diet is not tolerated or appropriate for the patient. 

NHS Surrey Heartlands does not recommend funding the treatment for refractory epilepsy in adults due to the limited evidence-base or for other neurological conditions such as autism and epilepsy syndromes in children and adults due to the limited evidence-base.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

An Open MRI Scanner is a solution for patients who cannot tolerate conventional MRI scans due to Claustrophobia or Obesity.

Thresholds and eligibility 

Access to open MRI scans is not routinely funded by NHS Surrey Heartlands and is subject to this restricted policy. 

The Surrey Priorities Committee has considered the evidence for open/upright MRI scans.

Conventional closed MRI scanners are considered to be the gold standard for producing diagnostic images. 

Open MRI scans provide lower quality images and take longer to produce than those from a conventional scanner. 

If open/upright MRI scans are to be provided they must be of 0.5 Tesla magnetic strength or above. 

NHS Surrey Heartlands supports the use of an open MRI scan where at least one of the following criteria are met: 

• Patients who are unable to tolerate conventional MRI due to claustrophobia despite trying a number of conservative measures to manage the anxiety, such as being offered mild sedatives, use of physical measures like noise cancelling headphones, and scanning feet first, and psychological measures such as reassurance and explanation, and specific treatments for anxiety from a therapist. The prescription for the mild sedative should be from a Radiologist. 

OR 

• Patients who are unable to fit in a conventional MRI scanner, e.g., due to obesity. 

OR 

• Patients who are unable to lie flat for the duration of a conventional MRI scan due to significant medical reasons, e.g., due to extreme pain. 

Any patient who requires an Open MRI scan and meets the criteria above should be referred to an appropriate open MRI scanner facility on a Provider-to-Provider basis. 

Clinicians requesting an open MRI scan for patients with debilitating symptoms which are thought to be due to weight bearing pathology can refer the case for assessment for funding on an individual basis via the Individual Funding Request process. Potential examples of this include examination of the lumbar spine, neck and spine muscles, knee, and hip joints.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.