COSMETIC PROCEDURES ANNUAL REPORT

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1 On behalf of NHS Mansfield & Ashfield, NHS Newark & Sherwood, NHS Nottingham North & East, NHS Nottingham West, NHS Rushcliffe & NHS Nottingham City Clinical Commissioning Groups COSMETIC PROCEDURES ANNUAL REPORT The Commissioning Policy for Cosmetic Procedures (All Ages) has been in place since April 2011 and identifies procedures that are considered to be primarily cosmetic and which have relatively small health benefits compared to other competing priorities for limited NHS resources. The current policy has very detailed and clear eligibility criteria for cosmetic procedures, which are intended to be fair, open and to include both consideration of clinical and cost effectiveness and also clinical expert opinion. Although PCTs were abolished at the end of March 2013 with the formation of 6 Nottinghamshire wide Clinical Commissioning Groups (s), policies that were in place prior to the 1 April 2013 remain in use to ensure a consistent approach. The former policy (developed by East Midlands Specialised Commissioning Group on behalf of the PCTs across the East Midlands) was presented to each of the governing bodies and formally adopted. Management of the Cosmetic Procedures Request process All cosmetic procedures requests from NHS Mansfield & Ashfield, NHS Newark & Sherwood, NHS Nottingham North & East, NHS Nottingham West, NHS Rushcliffe and NHS Nottingham City are assessed by the Individual Funding Request (IFR) Officer (hosted by NHS Mansfield & Ashfield ) and a Specialist Nurse Practitioner from Nottingham University Hospitals NHS Trust in line with the eligibility criteria set out in the policy. A Consultant Plastic Surgeon is available ad hoc for their clinical opinion for the more problematic requests. Those requests that do not meet the eligibility criteria set out in the policy will be rejected back to the practice, outlining reasons why the referral has been declined. All rejections are followed up with a letter to the GP and the patient. The IFR Officer left NHS Mansfield and Ashfield Clinical Commissioning Group in October There was reduced capacity in the team and during this time, the IFR Manager was responsible for managing all of the cosmetic procedures requests. The post was advertised and a new IFR Officer was appointed and joined the team in February Referral Management Centre Cosmetic Procedure Pathway Prior approval is required for all non-urgent cosmetic procedures. Therefore in order to capture the referrals and to ensure all requests for funding are considered in a consistent and equitable way the Clinical Assessment Service (CAS) for cosmetic procedures was established. In January 2014 the administrative function previously provided by the Nottingham County referral management centre based at Easthorpe House was decommissioned and NHS Mansfield and Ashfield, NHS Newark and Sherwood, NHS Nottingham North and East, and Nottingham West have now commissioned services from Collingham Health Education Centre (CHEC - Gateway). The clinical gateway has been co-designed with local clinicians and commissioner, and is available to clinicians on choose and book for all cosmetic procedures referrals. NHS Nottingham City cosmetic referrals are managed by their own referral management centre based at Standard Court. NHS Rushcliffe cosmetic referrals are managed by their own Clinical Assessment Service (CAS) based at Easthorpe House.

2 Benefits of using the Cosmetic Procedures CAS The benefits of referring patients through the CHEC/CAS are:- NHS resources are used appropriately Patients expectations are not raised unnecessarily for procedures that are not routinely commissioned, and eligibility criteria is applicable Delays are avoided by the patient attending out patients to be referred back for funding approval Only appropriate patients are referred into secondary care, thus reducing waiting times. Review of the Cosmetic Procedures Policy In October 2013 the East Midlands s considered the value and feasibility of maintaining a regional policy for cosmetic procedures. Following discussions at the Collaborative Commissioning Congress, the congress requested public health colleagues to produce evidence based recommendations regarding updates to the 2011 policy, with a view to its approval and formal adoption by s and inclusion in the 2014/15 contracts. Dr Tim Daniel and Dr Jonathan Gribbin were tasked with co-ordinating the public health review to include representation from Specialist Clinicians, including Dermatology, Plastics, General Surgery, ENT and Ophthalmology from the Trusts/s across the East Midlands. Following a series of meetings, a draft revised policy was produced and consultation with local networks, clinicians/s was undertaken, on the changes and any financial implications and public consultation on websites. The criteria for NHS funded procedures will be decided on the evidence of the procedures, clinical and cost effectiveness, on local and national guidelines, and on clinical expert opinion from local GPs and hospital clinicians. Unfortunately due to working in a more fragmented commissioning system, the revised policy has not met the original deadlines to be adopted by the s. It is anticipated that the policy will be ratified by the s in May/June (1) Types of Requests analysis Total number of procedures assessed against the Cosmetic Procedures Policy Figure 1 (overleaf) shows the total number of referrals received and assessed against the Cosmetic Procedures Policy, for each specific procedure where there is eligibility criteria for access to NHS funded treatment. The graphs show this data individually for each of the s within Nottinghamshire County and Nottingham City. Removal of benign lesions and sebaceous cysts are the most frequently requested procedures (see figures in bold), followed by scar revision and lipomas

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6 Figure 1 Procedure Mansfield & Newark & Nottingham North Nottingham NHS Nottingham Rushcliffe TOTAL Ashfield Sherwood & East West City Benign Skin Lesions Sebaceous Cysts Scar Reduction Lipomas/Lumps & bumps Breast Reduction Other Abdominoplasty Procedures not routinely commissioned* Breast Asymmetry Gynaecomastia Breast Augmentation Pinnaplasty (Age 5 18) Laser Treatment Breast Implant removal/insertion Blepharoplasty Rhinoplasty Botulinum Toxin for Axillary Hyperhidrosis Varicose Veins Re-refer on 2 week wait TOTAL * These requests include:- excision of excessive skin from all areas, other than the abdomen, facelifts, earlobe repair, mastopexy, labioplasty, liposuction, facelifts. All of these procedures are not routinely commissioned unless the treatment is: post-trauma, part of reconstruction following surgery (e.g. for cancer), part of the management of a congenital abnormality which results in a serious health function deficit, or for an iatrogenic condition arising from treatment previously delivered within the NHS.

7 (2) Cosmetic Procedures Request A total number of 654 requests were managed by the IFR Officer during the period 1 April March Figure 2 gives a breakdown of the outcomes of the referral requests by submitted into the Cosmetic Procedures CAS. Figure 2 Summary Mansfield & Ashfield Newark & Sherwood Nottingham North & East Nottingham West NHS Nottingham City Rushcliffe Approved Consultant Treatment Referral Rejected Does not meet criteria Referral Rejected Need more information Consultant Opinion Re referred on 2 week wait TOTAL Of the 654 referrals assessed by the CAS, 312 (48%) met the eligibility criteria for NHS funded treatment and 73 (11%) were approved for an outpatient appointment for further assessment and consultant opinion. 75 referrals were rejected back to the practice, due to insufficient information contained within the referral, thus making is difficult to make a full assessment. The type of information that is routinely omitted includes, BMI, sizes of lesions, and symptoms associated with the problem. A total number of 186 requests were sent back to GP s as patients did not meet the referral criteria for NHS funded treatment, making a cost avoidance of 20,832 in inappropriate outpatient appointments (based on 112 first OPA). After consideration against the SIGN guidelines 2003 for skin cancer and viewing clinical photographs, 8 referrals were rejected back to GPs for onward referral on the 2 week cancer pathway, as there was a concern that there was a significant possibility of malignancy. TOTAL - 7 -

8 Breast Reduction/Breast Asymmetry Requests Application of 3D body scanning in breast reduction and asymmetry patients has led to a more equitable and cost-effective assessment process for patients. In the period 1 April 2013 to 31 March 2014, 64 patients were referred by their GP for a body scan to determine if they were eligible for NHS funded surgical intervention. Of those requests a total of 17 (27%) referrals were rejected back to the practice, as the patient did not meet the BMI eligibility criteria (18-25 kg/m 2 ) to enable them to have a scan. 47 patients were eligible for a scan of which 13 patients met the eligibility criteria for NHS funded breast surgery. A total of 34 patients did not meet the eligibility criteria, 17 for breast asymmetry and 17 for breast reduction. Figure 3 provides a breakdown of the Breast Assessment funding requests made by the Clinical Commissioning Groups (s) broken down by procedure indicating how many passed and failed the process. Figure 3 Summary Total Number of Breast Assessment Requests Received Total number of patients not eligible for scanning Breast Asymmetry Scan PASS Breast Asymmetry Scan FAIL Breast Reduction Scan PASS Breast Reduction Scan FAIL NHS Nottingham City Newark & Sherwood Mansfield & Ashfield Nottingham West Nottingham North & East Rushcliffe TOTAL Cost Avoidance A total number of 47 patients were scanned at a cost of 264 per scan (total cost 12,408). 13 patients passed the scanning process and therefore were eligible for NHS funded breast surgery. The total spend for those patients that went on to have surgery including the cost of the scan was 32,383 (unit cost for breast surgery is 2,227). For those patients that did not meet the scan criteria (17) and therefore were not offered surgery, a total of 37,859 was avoided

9 Complaints There were no MP letters or formal complaints received by the Clinical Commissioning Groups (s) in about the outcome of funding decisions for cosmetics procedures. Appeals Appeals Mansfield & Newark & Nottingham North Nottingham NHS Nottingham Rushcliffe TOTAL Ashfield Sherwood & East West City Abdominoplasty Benign Skin Lesions Breast Reduction Breast Asymmetry Scar Reduction Other TOTAL There were 17 appeals received for those requests that were declined. The highest being for abdominoplasty with 9 appeals. All decisions were reconsidered and the funding decisions were upheld. All were offered the IFR and complaints routes. Two requests were received for consideration using the IFR process. Both were declined as they did not meet the IFR eligibility criteria, and no exceptionality was demonstrated in both cases. Priorities for Produce cosmetics quarterly reports for s Minimise the risk of negative media/external attention to s by maintaining and reviewing a robust decision making process. Assist the s to implement the new revised collaborative Cosmetics Procedures Policy. Provide resources +/- training for s in relation to reviewed Cosmetics Procedures Policy. Jane Urquhart, IFR Manager Aimee Jewsbury, IFR Officer April