Fit for the Future: decisions

A package of measures to put the local NHS on a more sustainable footing was agreed at a board meeting of NHS Basildon and Brentwood Clinical Commissioning Group (CCG) on Thursday 24 November.

This follows a nine week public consultation in which the CCG actively sought and listened to the views of local people on a range of proposed changes to the local Service Restriction Policy (SRP) and Intermediate Care Services.

Please scroll to the end of each table to see the relevant decision and the implementation date when any changes will come into effect.

Intermediate Care Services

Proposal

The CCG proposes to commission a new model of Intermediate Care which aims to manage patients with a combination of care in pa persons own home and through investment in community services and a reduced bed base specifically, the closure of beds at Mayflower Community Hospital (Billericay) and by combining the beds in Meadowview and Mayfield Ward (Thurrock Community Hospital) commissioned by all south Essex CCGs.

This will be undertaken by:

Phase 1 Creating Community Capacity

1) The CCG intend to invest circa £900k in additional provision/capacity focussed on a new

Rehabilitation Service aligned to the Single Point of Response within existing community

services. This will be primarily therapy led and work in partnership with a number of other

community services e.g. the Dementia Crisis Team, Integrated Care Teams and Reablement Service.

Phase 2 Reduced bed base in line with delivery of option 2

2) Through the introduction of the proposed community rehabilitation model, the need for intermediate care beds will reduce as patients will be supported to become as independent as possible at home. This change allows a number of existing intermediate care beds to be closed. The CCG would cease commissioning beds at Mayflower Community Hospital (Billericay) and with the south Essex CCGs, consolidate the bed base on Meadowview and Mayfield Wards on the Thurrock Community Hospital site.

The CCG would therefore commission:

- The Community Rehabilitation Service

- Thorndon Ward, Brentwood Community Hospital

- Mountnessing Court in Billericay

- In conjunction with south Essex CCGs, Meadowview Ward in Thurrock Community Hospital

Rationale:

The drivers that acted as a catalyst for the CCG to review the provision of inpatient Intermediate Care it commissions are:

- The QIPP (Quality, Innovation, Prevention, Productivity) challenge faced by the CCG meant that all areas of spend required review to ensure that we commission best value care.

- The Fit for the Future programme intention is that we commission a service model that supports patients to regain their optimum level of independence (this should be delivered in the patients normal place of residence)

- Changes to the Essex County Council (ECC) reablement contract which BBCCG invest £900k per year via the Better Care Fund

- ECC commissioning of 10 reablement beds in the community

Impact:

The efficiencies made through this proposed change would allow the CCG to increase the number of patients it supports within its Intermediate Care services – whilst the bed numbers will reduce, the number of patients that can be managed by the total system (home based and bed based care) would increase. In addition, the resulting saving from this new model will go towards bringing the CCG back to its statutory financial balance position which is vital in order for it to be viable organisation and fund future services for the local population.

Recommendation

It is recommended that subject to:
  • Negotiations with providers and other commissioners resulting in the achievement of the required level of saving

  • The risks continue to be appropriately mitigated that the CCG proceed in commissioning a community rehabilitation service that will lead to the cessation of commissioning beds in Mayflower Community Hospital in Billericay and the consolidation of Mayfield Ward and Meadowview Ward on the Thurrock Community Hospital site.

The CCG would then commission;

- The Community Rehabilitation Service
- Thorndon Ward, Brentwood Community Hospital (including the 8 Stroke beds)
- Mountnessing Court in Billericay
- In conjunction with south Essex CCGs, Meadowview Ward in Thurrock Community Hospital
- In conjunction with Thurrock CCG, the CCG continues to commission 8 stroke beds within
Thorndon Ward, Brentwood Community Hospital

Decision

Recommendation agreed
Implementation date: work will begin immediately with the aim of closing the beds by 1st April 2017

 Service Restriction Policy Review

E-cigarettes

Proposal

Basildon and Brentwood CCG are proposing that e-cigarettes and other novel nicotine containing products are not prescribed on the NHS until they have been fully evaluated, their place in therapy established, and formulary processes have been followed.

Smoking and stop smoking services fall under the remit of Public Health. NICE has issued guidance PH 45 https://www.nice.org.uk/Guidance/PH45 and associated quality standards. These recommend access to smoking cessation services, brief intervention and referral for smoking cessation. These services are available locally via Public Health.

The CCG feels there is existing sufficient support available to aid with the cessation of smoking.

Rationale

Electronic cigarettes are novel devices that deliver nicotine by heating and vaporising a solution that typically contains nicotine, propylene glycol and/or glycerol and flavourings.

A Public Health England (PHE) report1 has estimated that about 2.6 million adults used electronic cigarettes in 2015. The report concluded that as of yet the long term health harms are not known.

The report also estimated that nationally there are currently 1.8m prescription items dispensed each year that relate to smoking cessation (of which about 50% are nicotine replacement therapies). The nicotine replacement therapies that can be prescribed include:

  • skin patches
  • chewing gum
  • inhalators, which look like plastic cigarettes through which nicotine is inhaled
  • tablets, strips and lozenges, which you put under your tongue
  • nasal spray
  • mouth spray

These can all be prescribed by your GP or can be purchased within pharmacies.

Along with the prescribing of the above NRTs there is also the Public Health commissioned ‘NHS Stop Smoking Service’ that patients can access without having to contact their GP via telephone or the internet or via the online app. This service offers one-to-one sessions, group sessions or drop in services.

The CCG is not currently responsible for the commissioning of e-cigarettes. E-cigarettes are not currently prescribed as a nicotine replacement.

Impact

The CCG believes that the proposed changes would have little impact on the local population as described above there are several NRTs available that support smoking cessation along with other therapies available from pharmacies. These methods are clinically proven to assist with the stopping of smoking altogether as opposed to moving to an alternative way of smoking.

It has been estimated that costs for e-cigarettes would be around £1.1m per 100,000 population per year and that with a population of over 260,000 the CCG would face a significant financial pressures to an already challenged health system.

Recommendation

 The recommendation to the Board is to support the following:

  • for the CCG not to fund e-cigarettes
  • the CCG should review the position of prescribing of all nicotine replacements

Decision

Recommendation to not fund e-cigarettes was agreed
Implementation date: 28th November 2016

 

Gluten-free prescribed foods

Proposal

As part of a wider review into service restrictions Basildon and Brentwood CCG is proposing to stop all gluten free products on prescription with exceptions of pregnant women (from the point of confirmed pregnancy) and under 18s.

Rationale

Initially gluten free products were added to the list of products available on NHS prescription when they were not easily available for patients to purchase.

However, there are now a wide range of gluten free products available from supermarkets, the internet, health food stores and pharmacies. There are alternative products that are sold at prices that are considerably lower than the NHS is charged for prescribed foods. In addition to these products there is a wide variety of naturally gluten free food including; fresh fruit and vegetables, meat, poultry, fish, cheese and eggs.

In October 2016 NICE published the first quality standard* for Coeliac disease (Appendix 4), this quality standard outlines that patients should be able to access support and guidance on how to follow a gluten free diet.

Rationale - post consultation

Gluten free products are now available to purchase, food products for other allergies are not funded on prescription and many not as accessible as Gluten Free foods for example soya, nut and dairy free.

The consultation was seeking to ensure a reduction in inequity for our patient population and as such should ensure that the same position is taken for all of the population.

Impact

With the variety of gluten free products widely available to buy at a reasonable cost, the CCG believes there will be minimal impact to patients.

Recommendation

The recommendation to Board is to:
  • Support the proposal to stop all gluten free products on prescription with exceptions of pregnant women (from confirmation of pregnancy) and under 18s
  • Support further consideration or review by the CCG to stop prescribing gluten free products for pregnant women (from confirmation of pregnancy) and under 18s in line with the public feedback that this provides inequity across the population
  • If the above are approved, the Board is asked to support the below mitigating actions
Mitigating actions if recommendation approved:

  • Agree a process for those patients who have a pre-paid prescription certificate (https://www.gov.uk/geta-ppc) where it is only used for gluten free products

  • Ensure that the CCG website reflects that there are a range of dietary needs and can navigate patients to help and advice for accessing this regardless of diagnosis

  • Engage with organisations supporting those who require ‘free from’ allergens diet to ensure that the CCG is able to provide navigation on the website

  • Write requesting ‘free from’ allergens foods are more accessible locally in supermarkets and at other retailers including pharmacies

Decision

The following recommendation was approved:
Support the proposal to stop all gluten free products on prescription with exceptions of pregnant women (from confirmation of pregnancy) and under 18s. In addition the CCG will take forward the identified mitigating actions.
Implementation date: 1st January 2017

 

Toric Intraocular Lens Implants for Astigmatism 

Proposal

As part of a wider review of service restrictions Basildon & Brentwood CCG are proposing to cease the funding of Toric intraocular lens implant (IOLs) for astigmatism.

 Rationale

The standard IOLs design used for cataract surgery in the NHS is the monofocal IOLs. The Toric IOLs are the so called ‘premium lens’ however these come at a greater cost than the standard.

The proposal the CCG is making isn’t to stop funding all procedures of IOLs and correction of cataracts just the Toric IOLs. The Toric IOLs works towards patients not requiring glasses as it potentially improves astigmatism however with limited funds the CCG aim is to bring people back to a pre cataract position not correction of astigmatism.

The CCG’s approach to the current financial challenges is to prioritise the limited funding it has so that the local population has access to the healthcare that is most needed. This assessment of need is made across the whole population of Basildon & Brentwood CCG and, wherever possible, on the basis of best evidence on what is clinically proven to work.

 Impact

The efficiencies made by not funding this procedure will go towards bringing the CCG back to its statuary financial balance position which is vital in order for it to be viable organisation and fund future services for the local population.

As there are alternative IOLs procedures available the CCG believes there would be limited impact to patients.

 Recommendation

The recommendation to the Board is that Basildon and Brentwood CCG should not fund
Toric Intraocular Lens Implants for Astigmatism. The basis for this recommendation is that
the CCG already funds standard monofocal IOL and as the Toric lens is a premium lens it will
be more expensive.

Decision

Recommendation approved
Implementation date: 28th November 2016

 

In-vitro Fertilisation (IVF) and Assisted Conception (new referrals)

Proposal

In 2015 NHS Basildon and Brentwood CCG undertook a Public Consultation to cease specialist fertility service provision. No decision has yet been made following the consultation. The consultation was based on two options;

Option 1 – No change to the existing policy


Maintenance of the status quo. Assisted conception, including offering three cycles of IVF, would continue to be available to those who meet the eligibility criteria. Outside the agreed eligibility criteria, clinically exceptional cases would be considered by application to the CCG’s exceptional cases panel.

Option 2 – Decommission Specialist Fertility Services


Under this option the CCG would cease commissioning specialist fertility services. Patients would only be able to access gynaecology services within local district general hospital. A summary of the fertility services that will be available under this option is defined in Appendix 1.

If implemented, this policy would apply to only those patients referred onto specialist fertility pathways from the date of implementation. Any patient on an existing pathway would be able to conclude their pathway in line with the current restriction policy1.

Clinically exceptional cases would be considered by application to the CCG’s Individual Funding Request Panel. The CCG would keep and monitor the impact of the change on both services and people with fertility problems. There would be a review of the policy annually and further changes could be applied, including a return to wider access to specialist fertility services, if this was considered to be affordable.

The only exception to this would be to continue to commission fertility preservation.
  Proposed criteria Current criteria
Egg harvesting
and storage for
patients
undergoing
treatments
likely to affect
their fertility

The CCG proposal is that they fund the harvesting and storage of eggs that for those undergoing treatment for cancer and other medical conditions that affect their reproductive functions using the following criteria.

The CCG will fund the harvesting of eggs up to the day before the patient’s 43rd birthday.

  • The CCG will fund the storage:
    until the age of 25 if harvested before her 20th birthday
  • for 5 years if harvested between her 20th and 38th birthday
  • until her 43rd birthday if harvested after the age of 38.

If the patient dies whilst their eggs are in storage the CCG will no longer fund the storage 3 months from the person dying.

* Patients can choose to fund storage themselves beyond the NHS funded period.

 

When considering and using cryopreservation for people before starting chemotherapy or radiotherapy that is likely to affect their fertility, follow recommendations in ‘The effects of cancer treatment on reproductive functions’ (2007). When using cryopreservation to
preserve fertility in people diagnosed with cancer, use sperm, embryos or oocyctes.

Offer oocyte or embryo cryopreservation as appropriate to women of reproductive age (including adolescent girls) who are preparing for medical treatment for cancer that is likely to make them infertile if:

  • they are well enough to undergo ovarian stimulation and egg collection and
  • this will not worsen their condition and
  • enough time is available before the start of their cancer treatment.

Cryopreserved material may be stored for an initial period of 10 years. Following cancer treatment, couples seeking fertility treatment must meet the defined eligibility criteria

Sperm
collection and
storage for
patients
undergoing
treatments
likely to affect
their fertility

The CCG proposal is that they fund the collecting and storage of sperm that for those undergoing treatment for cancer and other medical conditions that affect their reproductive functions using the following criteria.

The CCG will fund the collecting of sperm up to the day before the patient’s 43rd birthday.

The CCG proposal is that they fund storage of sperm that have been frozen already for those undergoing treatment for cancer and other medical conditions that affect their reproductive functions.

The CCG will fund the storage:

  • until the age of 25 if harvested before his 20th birthday
  • for 5 years if harvested between his 20th and 38th birthday
  • until his 43rd birthday if harvested after the age of 38

If the patient dies whilst their sperm are in storage the CCG will no longer fund the storage 3 months from the person dying.

* Patients can choose to fund storage themselves beyond the NHS funded period.

Offer sperm cryopreservation to men and adolescent boys who are preparing for medical treatment for cancer that is likely to make them infertile.

Local protocols should exist to ensure that health professionals are aware of the values of semen cryostorage in these circumstances, so that they deal with the situation sensitively and effectively.
Cryopreserved material may be stored for an initial period of 10 years.

Following cancer treatment, couples seeking fertility treatment must meet the defined eligibility criteria

There are other specialist services commissioned by NHS England, which are available separately, and not covered by BBCCG service restrictions policy. For example, BBCCG is not responsible for commissioning Pre-implantation Genetic Diagnosis and associated IVF/ICSI and specialist fertility services for members of the Armed Forces. These arrangements are not affected by this paper.

 Rationale

In 2015 the CCG’s Turnaround Programme required the CCG to review all of its commissioning arrangements to identify whether services commissioned are a priority for the CCG. Those that are not priorities need to be reviewed to seek opportunities for delivering savings to protect priority provision. As part of this review, the CCG has reviewed the provision of Specialist Fertility Services.

 Impact

The efficiencies made by not funding this procedure will go towards bringing the CCG back to its statutory financial balance position which is vital in order for it to be viable organisation and fund future services for the local population.

Recommendation

The recommendation to Board is to proceed with “Option 2” i.e. decommissioning specialist fertility
services for all new referrals and where referral has taken place to a specialist provider where active treatment has not commenced from the date of implementation 28 November 2016. This is with exception of fertility preservation where the time periods for storage have been reduced for some patients but the criteria has been extended to cover other medical conditions that affect
reproductive function and not just cancer. The CCG would continue to commission the range of
gynaecology services from local district general hospitals set out in Appendix 1.

Appendix 1

Summary of Fertility Services that will continue to be commissioned under Option 2
Decommissioning of Specialist Fertility Services

  •  A thorough history will be taken from each couple including duration of sub-fertility;
    medical history including current medical problems and treatments; number and
    outcome of any conceptions with current or previous partner; social history including
    smoking and alcohol intake.

  • The female partner will also be asked about the following: any past or current
    gynaecology problems; whether she has been pregnant previously and the outcome of
    the pregnancies; her menstrual history and any menstrual problems; cervical smear
    history; folic acid intake.

  • Blood tests will be arranged for the woman for FSH, LH, Prolactin, Testosterone,
    Oestradiol and Thyroid function tests and for progesterone.

  • A pelvic examination is usually performed and screening tests for Chlamydia taken.
    Cervical smears are taken if relevant.

  • Semen analysis is organised for the male partner; two tests may be necessary one month
    apart.

  • A follow-up visit is arranged for 8-10 weeks to discuss results and management.

  • Results of the investigations are discussed with the couple.

  • A care pathway is discussed and appropriate management of the sub-fertility arranged.

  • Further care will depend on the underlying problem and could involve:

  • Ovulation induction with Clomiphene.

  • Management of Polycystic Ovary Syndrome.

  • Follicle scanning to determine the growth of the follicle and approximate time of
    ovulation.

  • Management of endometriosis.

  • Further exploration of tubal patency if unconfirmed by Hycosy eg: laparoscopy and dye
    under general anaesthetic.
    The following procedures will also be commissioned;

    Outpatient - Consultation

                  Follicular tracking scan
                  Fertility assessment ultrasound scan
                  Ovulation induction treatment with drugs
                  Hysterosalpingography

Day case - Laparoscopy + dye
                Laparoscopy + ovarian drilling
                Hysteroscopy
                Hysteroscopy + division of adhesions
                                    + resection of fibroid
                                    + tubal cannulation
                Laparoscopy + tubal surgery
                Laparoscopy + treatment of endometriosis

Inpatient - Myomectomy

Decision 

Amended recommendation approved - the CCG cease to commission specialist fertility for any individual referred to specialist fertility services on or after 1st December 2016 (those referred prior to this date will be treated as existing service users and provision will be in line with the policy decision for In-vitro Fertilisation (IVF) and Assisted Conception (existing treatment)
Implementation date: 1st December 2016

 

In-vitro Fertilisation (IVF) and Assisted Conception (existing treatment)

Proposal

In 2015 NHS Basildon and Brentwood CCG undertook a Public Consultation to cease specialist fertility service provision. No decision has yet been made following the consultation. However, if the proposal (as per consultation in 2015) were to be approved by the CCG Board, then services would be decommissioned for those requiring referral for tests or procedures that were deemed specialist (specialist assisted conception services e.g. IVF).The CCG would continue to fund those tests or procedures that would diagnose fertility problems and those that can be undertaken in a local hospital to aid fertility.

We are now consulting on proposals for people who have already been referred for specialist fertility treatment, for whom the decision of what the CCG will fund for them was not addressed in the original consultation.The proposals for people who have already been referred or are receiving treatment for specialist assisted conception services cover the following:

• In Vitro Fertilisation (IVF) with or without Intracytoplasmic Sperm Injection (ICSI)

• Frozen Embryo Transfer

• Embryo/Blastocyst Freezing and Storage

• Surgical Sperm Recovery (Testicular Epididymal Sperm Aspiration (TESA)/Percutaneous Sperm Aspiration (PESA) including storage where required)

• Intrauterine Insemination (IUI) - unstimulated

• Donor Oocyte Cycle

• Donor Sperm Insemination

• Egg Storage for Patients Undergoing Treatments likely to affect their fertility

• Sperm Storage for Patients Undergoing Treatments likely to affect their fertility

For those patients who have already been referred for specialist fertility treatment and are in the process of receiving the above specialist services, the CCG is proposing to introduce the following restrictions:

Procedure Proposal What it currently is
In Vitro Fertilisation (IVF) with or without Intracytoplasmic Sperm Injection (ICSI)

For anyone who has progressed to IVF the CCG is proposing that they will fund the current cycle with a cycle being defined as:

  • One fresh and up to one frozen transfer (the number of embryos per transfer is not defined)

* Where more embryos are frozen than can be used for the proposed cycle/s patients can choose to fund storage themselves.

This will include the storage of any frozen embryos for 1 year following egg collection. Patients should be advised at the start of treatment that this is the level of service available on the NHS and following this period continued storage will need to be funded by themselves or allowed to perish.For anyone who has already had one fresh and one frozen transfer of their current cycle and has already started the process for the next round of frozen e.g. started taking the drugs then that the round would be funded.

Active treatment must have been commenced on or before the 28 November 2016.

For anyone who has frozen embryos stored which under previous arrangements would have been eligible for NHS funded services then any frozen embryos will be stored for 1 year from 28 November 2016.Patients can choose to fund embryo storage themselves beyond the NHS funded period.

A full cycle of IVF treatment, with or without intracytoplasmic sperm injection (ICSI), should comprise 1 episode of ovarian stimulation and the transfer of any resultant fresh and frozen embryo(s). This will include the storage of any frozen embryos for 1 year following egg collection. Patients should be advised at the start of treatment that this is the level of service available on the NHS and following this period continued storage will need to be funded by themselves or allowed to perish.

An embryo transfer is from egg retrieval to transfer to the uterus.
The fresh embryo transfer would constitute one such transfer and each subsequent transfer to the uterus of frozen embryos would constitute another transfer.

Before a new fresh cycle of IVF can be initiated any previously frozen embryo(s) must be utilised.

Where couples have previously self-funded a cycle then the couples must utilise the previously frozen embryos, rather than undergo ovarian stimulation, egg retrieval and fertilisation again.

Frozen Embryo
Transfe

For those who have previously had CCG funding and have embryos in storage the CCG is proposing:

  •  Funding only where considered as part of the current cycle (as above)

* Where more embryos are frozen than can be used for the proposed cycle/s patients can choose to fund storage themselves.


For definition and timeframe please refer to section on IVF cycle

For women less than 37 years of age only one embryo or blastocyst to be transferred in the first cycle of IVF and for subsequent cycles only one embryo/blastocyst to be transferred unless no top quality embryo/blastocyst available then no more than 2 embryos to be transferred 137


* Where more embryos are frozen than can be used for the proposed cycle/s patients can choose to fund storage themselves.

For definition and timeframe please refer to section on IVF cycle.

For women age 37-39 years only one embryo/blastocyst to be transferred unless no top quality embryo/blastocyst available then no more than 2 embryos to be transferred.

For women 40-42 years consider double embryo transfer.

A fresh cycle would be considered completed with the attempt to collect eggs and transfer of a fresh embryo.

Embryo/Blastocyst
Freezing and Storage

Where embryos have previously been stored the CCG is
proposing:

  • Freezing and storage for up to one year from the date
    of egg collection (as previous arrangements)*


* Patients can choose to fund embryo / blastocyst storage
themselves beyond the NHS funded period.

 
Surgical Sperm
Recovery Testicular
Epididymal Sperm Aspiration (TESA) / Percutaneous Sperm Aspiration (PESA) including storage where required)

Where this is part of a current cycle the proposal is that:

  • The CCG will fund this for the current cycle only.
  • The CCG will not fund storage beyond the current funded cycle requirement.

* Patients can choose to fund sperm storage themselves beyond the NHS funded period.

For definition and timeframe please refer to section on IVF and IUI cycle

 
Intrauterine
Insemination (IUI) - unstimulated

The CCG proposal is that:

  • the patient is able to complete the current cycle of IUI.

Where they have started active treatment on or before the 28 November 2016 e.g. had scanning ahead of the IUI.

NICE guidelines state that unstimulated intrauterine insemination as a treatment option in the following groups as an alternative to vaginal sexual intercourse:

  • people who are unable to, or would find it very difficult to, have vaginal intercourse because of a clinically diagnosed physical disability or psychosexual problem who are using partner or donor sperm
  • people with conditions that require specific consideration in relation to methods of conception (for example, after sperm washing where the man is HIV positive)
  • people in same-sex relationships

Due to poor clinical evidence, a maximum of 6 cycles of IUI (as a replacement for IVF/ICSI and without donor sperm).

Donor Oocyte Cycle

The CCG proposal is that:

  • the patient is able to complete the current donor oocyte cycle
  • Up to 2 transfers* Patients can choose to fund oocyte / embryo /blastocyst storage themselves.

The patient may be able to provide an egg donor; alternatively the patient can be placed on the waiting list, until an altruistic donor becomes available. If either of the couple exceeds the age criteria prior to a donor egg becoming available, they will no longer be eligible for treatment.

This will be available to women who have undergone premature ovarian failure (amenorrhoea 6 months and a raised FSH 25) due to an identifiable pathological or iatrogenic cause before the age of 40 years or to avoid transmission of inherited disorders to a child where the couple meet the other eligibility criteria.

Donor Sperm
Insemination

The CCG proposal is that:

  • the patient is able to use donated sperm for the current cycle of:
    o IUI
    o IVF

* Patients can choose to fund sperm storage themselves beyond the NHS funded period.

For definition and timeframe please refer to section above on IVF and IUI

The use of donor insemination is considered effective in managing fertility problems associated with the following conditions:

  • obstructive azoospermia
  • non-obstructive azoospermia
  • severe deficits in semen quality in couples who do not wish to undergo ICSI.
  • Infectious disease of the male partner (such as HIV)
  • Severe rhesus isoimmunisation
  • Where there is a high risk of transmitting a genetic disorder to the offspring.

Donor insemination is funded up to a maximum of 6 cycles of Intrauterine Insemination (IUI).

Egg storage for patients undergoing treatments likely to affect their fertility

The CCG proposal is that they fund storage of eggs that have been frozen already for those undergoing treatment for cancer and other medical conditions that affect their reproductive functions.

The CCG will fund the storage:

  • until the age of 25 if harvested before her 20th birthday
  • for 5 years if harvested between her 20th and 38th birthday
  • until her 43rd birthday if harvested after the age of 38. If the patient dies whilst their eggs are in storage the CCG will no longer fund the storage 3 months from the person dying.

* Patients can choose to fund storage themselves beyond the NHS funded period.

If the person is already deceased the 3 months commences on 28 November 2016.

When considering and using cryopreservation for people before starting chemotherapy or radiotherapy that is likely to affect their fertility, follow recommendations in ‘The effects of cancer treatment on reproductive functions’ (2007).

When using cryopreservation to preserve fertility in people diagnosed with cancer, use sperm, embryos or oocyctes.

Offer oocyte or embryo cryopreservation as appropriate to women of reproductive age (including adolescent girls) who are preparing for medical treatment for cancer that is likely to make them infertile if:

  • they are well enough to undergo ovarian stimulation and egg collection and
  • this will not worsen their condition and
  • enough time is available before the start of their cancer treatment.

Cryopreserved material may be stored for an initial period of 10 years.
Following cancer treatment, couples seeking fertility treatment must meet the defined eligibility criteria.

Sperm storage for patients undergoing treatments likely to affect their fertility

The CCG proposal is that they fund storage of sperm that have been frozen already for those undergoing treatment for cancer and other medical conditions that affect their reproductive functions.

The CCG will fund the storage:

  • until the age of 25 if harvested before his 20th birthday
  • for 5 years if harvested between his 20th and 38th birthday
  • until his 43rd birthday if harvested after the age of 38.

If the patient dies whilst their sperm are in storage the CCG will no longer fund the storage 3 months from the person dying.

* Patients can choose to fund storage themselves beyond the NHS funded period.

If the person is already deceased the 3 months is from the 28 November 2016.

Offer sperm cryopreservation to men and adolescent boys who are preparing for medical treatment for cancer that is likely to make them infertile.

Local protocols should exist to ensure that health professionals are aware of the values of semen cryostorage in these circumstances, so that they deal with the situation sensitively and effectively.

Cryopreserved material may be stored for an initial period of 10 years.
Following cancer treatment, couples seeking fertility treatment must meet the defined eligibility criteria.

 

 Rationale

 The CCG believe that this decision supports transparency and equity of approach to the population and reduces the perception that for some people we are funding fully in line with NICE guidance whilst for others not supporting funding at all.

Impact

 The CCG also considers that withdrawing support for funding for those in the system is unfair without notification of this change in decision or approach.

The efficiencies made by not funding this procedure will go towards bringing the CCG back to its statutory financial balance position which is vital in order for it to be viable organisation and fund future services for the local population.

 Recommendation

 The recommendation to the Board members is to:
  • approve the recommended proposal for each component of Assisted conception and IVF as outlined in the paper above

  • if approved by the Board – members are asked to also support the following actions:

           o CCG writes a letter for Providers to send to existing patients outlining the outcome of the
           proposal

           o CCG ensures that following Board decision all providers are notified as soon as possible of
           the decision

Amended recommendations:

1) Approve the redefinition of an IVF cycle as a maximum one fresh and one frozen transfer.

2) Amend the IVF section with:

• If an individual has been referred on or before 30 November 2016 to specialist fertility services but have not completed the first cycle of IVF (as defined in recommendation one above) then one cycle of IVF would be funded to completion (as defined in recommendation one).
• If an individual patient has completed their first and has started active treatment for their second or third cycle as at 1 January 2017 then that cycle will be funded to completion (as defined in recommendation one).

3) Approve the funding of up to a maximum of six cycles of intrauterine insemination (IUI) prior to the first cycle of IVF.

4) Approve the implementation date for the storage of eggs and sperm as 1 December 2016.

5) Approve the cessation of funding for IVF and assisted conception treatment for all other individuals in the system.

Decision

Amended recommendation approved

A person undergoing existing treatment is defined as someone for whom a referral to specialist fertility services was made on or before 30th November 2016.
Implementation date: 1st December 2016

Detail:

NICE definition of a full cycle of IVF

NICE defines a full cycle of IVF as one in which one or two embryos produced from eggs collected after ovarian stimulation are replaced into the womb as fresh embryos (where possible), with any remaining good quality embryos frozen for use later. When these frozen embryos are used later, this is still considered to be part of the same cycle.

The CCG Board decided that a cycle will be defined as a maximum of one fresh and one frozen transfer.

Existing patients are defined as those who have had a referral made to a specialist provider on or before 30 November 2016.

First cycle

Individuals who have been referred to a specialist provider (on or before 30th November 2016) or who are receiving treatment from a specialist provider will be funded for intrauterine insemination (IUI) and for one cycle of IVF with a maximum of one fresh and one frozen transfer* but will not go on to subsequent IVF cycles and no further embryo transfers will be funded.

Second cycle

Individuals receiving active treatment for a second cycle on 1 January 2017 i.e. taking medication this second cycle will be funded to a maximum of one fresh and one frozen transfer*. The individuals will not go on to a third cycle and no further embryo transfers will be funded.

Third cycle

Individuals receiving active treatment for a third cycle on 1 January 2017 i.e. taking medication this third cycle will be funded to a maximum of one fresh and one frozen transfer*. No further embryo transfers will be funded. No further cycles will be funded.

The CCG Board decided that it will fund a cycle defined as a maximum of one fresh and one transfer. However, if an individual is receiving active treatment i.e. taking medication in preparation for the transfer of a second or subsequent frozen embryo on 1 January 2017 this transfer for which the individual is receiving active treatment will be completed. No further transfers or cycles will be funded.

Embryo storage

Any extra embryos that have generated from an NHS funded cycle of IVF will have storage funded by the NHS for one year. From 1 February 2018 individuals will have the option to fund storage themselves if they wish storage to continue.

Successful pregnancy

If at any stage during the process a successful pregnancy occurs (even if it occurs naturally) any subsequent specialist fertility treatment will not be funded.

 

Simultaneous joint replacement

Proposal

As part of a wider review of service restrictions Basildon & Brentwood CCG are proposing to cease the funding of the following joint replacement procedures:

• simultaneous hip replacement i.e. replacing both hips at the same time
• simultaneous knee replacement i.e. replacing both knees at the same time
• simultaneous shoulder joint replacement

Rationale

Simultaneous joint replacement, both joints would be replaced at the same time. Whilst there may be an advantage that the surgery is undertaken in one go, it does pose greater risks. By having both joints replaced at the same time the surgery is therefore longer which alone can increase the risk of complications.

Recovery and rehabilitation time may be increased when having simultaneous joint replacements and therefore this can place a greater demand on the body which in turn could lead to a complex and more expensive package of care being required.

The CCG’s approach to the current financial challenges is to prioritise the limited funding it has so that the local population has access to the healthcare that is most needed. This assessment of need is made across the whole population of Basildon & Brentwood CCG and, wherever possible, on the basis of best evidence on what is clinically proven to work.

The proposed change would mean that simultaneous joint replacement inserts would no longer be funded under the CCG however staged joint replacement would still be.

Impact

It is suggested that staged joint replacement poses less risk to older patients and patients with heart conditions whilst also reducing the length of time patients are in hospital. The majority of patients having total joint replacements are over the age of 65 and whilst having staged joint replacements will mean having two episodes of surgery the main advantage is that it reduces risks of complications.

The efficiencies made by no longer funding these procedures will go towards bringing the CCG back to its statutory financial balance position which is vital in order for it to be viable organisation and
fund future services for the local population.

Recommendation

The recommendation to the Board is that the CCG should not fund Simultaneous Joint
Replacements.

Decision

Recommendation approved
Implementation date: 1st January 2017

 

Pain treatments/injections (back, hip and leg)

Proposal

As part of a wider review of service restrictions Basildon & Brentwood CCG are proposing to cease the funding of pain insert procedures (facet joint injections, hip & spinal injections).

For note:
These procedures are not those available at General Practice but those that are required referral to be undertaken at an acute hospital.

Rationale

The CCG’s approach to the current financial challenges is to prioritise the limited funding it has so that the local population has access to the healthcare that is most needed. This assessment of need is made across the whole population of Basildon & Brentwood CCG and, wherever possible, on the basis of best evidence on what is clinically proven to work.

As a result of this, the CCG has identified procedures that are of either limited clinical value or that
does not cater for the wider needs of the population. Therefore it has been proposed to implement these changes in order for the local health economy and services to be sustainable.

The CCG in consultation with the Dr Simon Thompson (Pain Specialist Consultant, Basildon Hospital) have developed a criteria (see below proposed criteria) for injections for diagnostic purposes that supports both current and proposed NICE Guidance and reflects the position of the British Pain Society.

Impact

The proposed changes would mean that secondary care (acute) pain injections (facet joint injection, hip and spinal injection) would no longer be funded by the CCG except as a diagnostic intervention.
There will still be a range of pain relief interventions available that will be funded and/or can be prescribed. These may include (list not exhaustive):
  • Community Pain Management Programme
  • Palliative Medications to manage pain
  • Injections administered by General Practice
  • Conservative Pain Management through Physiotherapy

Recommendation

The Board is asked to approve the following recommendations:

  • The CCG only commission Back, Hip and Spine Injections (indications as outlined in proposal above) as a diagnostic procedure for Facet Joint Pain (posterior spinal element/facetogenic back and leg pain)

  • The CCG only commission Back, Hip and Spine Injections (indications as outlined in proposal above) as a diagnostic procedure for Sacro-iliac joint mediated back and leg pain

  • The CCG only commission Back, Hip and Spine Injections (indications as outlined in proposal above) as a diagnostic procedure for Discogenic and radicular back pain

Decision

Recommendation approved
Implementation date: 1st January 2017

 

Spinal Cord Stimulation (SCS)

Proposal

As part of a wider review of service restrictions Basildon & Brentwood CCG are proposing to cease the funding of pain insert procedure (spinal cord stimulation).
(Definition - spinal cord stimulation involves placing a series of electrical contacts in the spine near the region that supplies nerves to the painful area. The procedure is a minimally invasive surgical technique).

Rationale

The CCG’s approach to the current financial challenges is to prioritise the limited funding it has so that the local population has access to the healthcare that is most needed. This assessment of need is made across the whole population of Basildon & Brentwood CCG and, wherever possible, on the basis of best evidence on what is clinically proven to work.

As a result of this, the CCG has identified procedures that are either limited clinical value or that does not cater for the wider needs of the population or therefore it has been proposed to implement these changes in order for the local health economy and services to be sustainable.

Impact

The proposed changes would mean that pain procedure (spinal injection) would no longer be funded by the CCG however there will still be a range of alternate pain relief methods available that will be funded and/or can be prescribed.

For patients who already have a Spinal Cord Stimulator device in situ – they would continue to receive the on-going support they require. However, this proposal would determine where they would receive this support in the future.

Recommendation

The Board is asked to approve the following:
  • That if the CCG can’t agree a:
            o Risk (cost) managed local service model by 5 December 2016
            o The Trust (BTUH) can’t evidence with a project plan detailing the milestones to
               delivery (agreed with NHS England) the progression of the BTUH Pain service
               becoming accredited

  • Then the Spinal Cord Stimulation Service will be transferred to NHS England Specialised Commissioning

Decision

Recommendation approved
Implementation date: 1st January 2017

 

Travel Vaccinations

Proposal

In line with national recommendations from PrescQIPP, Basildon and Brentwood CCG is proposing to put in place a policy which clarifies the position of certain vaccines when requested in relation to travel abroad. This is to ensure that certain vaccines which are not allowed on the NHS for travel purposes, are not prescribed on FP10 prescription.

Rationale

NHS patients are entitled to receive free advice on travel vaccinations, however, only some vaccinations required for travel are available on the NHS. This includes Hepatitis A vaccine, Typhoid vaccine, combined hepatitis A and typhoid vaccine, combined Tetanus, diphtheria and polio vaccine and Cholera vaccine.

Other vaccines such as Hepatitis B, Meningitis ACWY, Yellow fever, Japanese B encephalitis, Tick bourne encephalitis and Rabies vaccine are not remunerated by the NHS as part of additional services in relation to travel abroad, and these vaccines should not be prescribed on FP10 prescription. It is proposed that a GP practices may charge a registered patient for the immunisation if requested for travel, or the patient may be given a private prescription to obtain the vaccines.

In addition, the combined hepatitis A/hepatitis B vaccine is prescribable on the NHS because it contains hepatitis A. However, because hepatitis B is not commissioned by the NHS as a travel >vaccine, Basildon and Brentwood CCG does not support the prescribing of this item. Patients requiring both vaccines for travel purposes should receive hepatitis B privately.

Impact

There is currently very little prescribing of Meningitis ACWY, Yellow fever, Japanese B encephalitis, Tick bourne encephalitis and Rabies vaccines on FP10 prescription in BBCCG, and therefore this policy would help to ensure no new prescribing. There is however a BBCCG spend of almost £75k per year associated with Hepatitis B vaccine, as well as the combined hepatitis A/hepatitis B vaccine. It is envisaged that implementation of local policy would reduce any inappropriate prescribing for travel abroad, and could produce annual savings to the CCG of approximately £75k across the course of a year.

Recommendation

The recommendation to the Board is that Basildon and Brentwood CCG should not fund the
following travel vaccinations as these are not standard NHS vaccines:
  • Hepatitis B
  • Meningitis ACWY
  • Yellow fever
  • Japanese B encephalitis
  • Tick bourne encephalitis
  • Rabies vaccine

 Decision

Recommendation approved
Implementation date: 28th November 2017

 

Bariatric  surgery

Proposal

As part of a review into service restrictions Basildon and Brentwood CCG was proposing not to fund bariatric surgery.

NHS England transferred responsibility for commissioning Bariatric surgery to the CCG from 1 April 2016. This service is provided from specialised centres so patients must travel to London for this surgery.

Whilst the funding will return with the service, the CCG feel that it should consult on not providing this service to the population and instead work with Public Health to promote healthier lifestyles and tackle obesity rather than managing the problem once it occurs. However, as stipulated in the latest NICE guidance (CG189; 2014), there will be a group of patients, especially people of different ethnicity, who may benefit from bariatric surgery as they are likely to develop more complex health conditions (especially Diabetes) if they are already significantly overweight.

Obesity Weight Management

Obesity rates have doubled in 20 years (men 24%, women 26%) but Basildon (30.2%) has a greater percentage of adults that are classified as obese or excess weight compared to the regional and national average, in sharp contrast with Brentwood (18.6%). In regards to children, the rate of obesity is higher in Basildon than Brentwood with both tracking the general upward trend in the past few years but levelling off now. There is over 10% decrease in children with ‘healthy weight’ between Reception year and Year 6 cohorts.

Definition - Bariatric surgery

This type of surgery is only available on the NHS to treat people with potentially life-threatening obesity when other treatments, such as lifestyle changes, haven't worked.

Potentially life-threatening obesity is defined as:

  • having a body mass index (BMI) of 40 or above
  • having a BMI of 35 or above and having another serious health condition that could be improved if you lose weight, such as type 2 diabetes or high blood pressure
Adults who have recently been diagnosed with type 2 diabetes may also be considered for an
assessment for weight loss surgery if they have a BMI of 30-34.9.

Rationale

The CCG wish to support people to self-manage their condition, empowering them to have greater control over their lives’. Where there is a pressing clinical need, cases will be considered on an exceptional basis. The CCG feel that through working with Public Health and our providers to support people to better manage their conditions and engage and participate in improving their wellbeing the need for bariatric surgery should decrease whilst outcomes for patients should improve.

Both Basildon and Brentwood Health and Well Being Boards (HWB) support the need to prevent obesity and manage it so as to reduce the need to progress onto surgical intervention.

Impact

 It is suggested that the proposal should not greatly impact patients with obesity and weight issues as there are already various weight management services available that teach nutrition and lifestyle changes rather than opting for surgery. With any surgery there are risks and if patients can lose weight themselves naturally with the support of local services they are not going to be exposed to the risks of bariatric surgery and any possible complications.

Recommendation

The recommendation to the Board is that they:

  • Support the proposal to fund bariatric surgery (via Individual Prior Approval), using the NHS England criteria (see below) that was in place prior to the transfer of the service from NHS England to CCGs.
  • Support and approve the mitigation to this decision listed below
          o ensure that through closer working with Public Health the CCG promote and                        refer patients for support for Tier 2 (Lifestyle interventions weight management                  services) that Public Health commission
          o ensure access for Tier 3 (specialist weight management services) for those that are            outside of the Tier 2 criteria and that the CCG monitor the impact and outcomes                  of the Tier 3 weight management service
          o ensure that information is available on the CCG website to navigate people to weight          management programmes and support
NHS England criteria for Bariatric Surgery that the CCG are proposing to adopt:

Surgery should only be considered as a treatment option for people with morbid obesity providing
all of the following criteria are fulfilled:

• The individual is considered morbidly obese.

For the purpose of this guidance and in accordance with previous and current NICE Guidance,
obesity surgery will be offered to adults with a BMI of 40kg/m2 or more, or between 35 kg/m2 and 40kg/m2 or greater in the presence of other significant diseases. However, NICE have recently updated their guidance on obesity surgery (NICE CG189). This expands the above criteria - to the consideration of newly diagnosed diabetics ( 30 to < 35, for assessment of obesity surgery. Moreover, patients with newly diagnosed diabetes within the former group (≥35) should be expedited for consideration of obesity surgery. All groups will have been treated in a Tier 3 specialist weight management service. NICE guidance also includes consideration of assessment of newly diagnosed Asian diabetes patients at BMI levels2.5 kg/m2 less.

• There must be formalised MDT led processes for the screening of comorbidities and the detection
of other significant diseases.

These should include:

• Disease / condition / Risk factor identification, diagnosis, severity / complexity assessment, risk
stratification/scoring and appropriate specialist referral for specialist medical management. Such
medical evaluation and optimization is mandatory prior to entering a surgical pathway.

• The individual has recently received and complied with a local specialist weight management
programme (non-surgical Tier 3 mostly and Tier 4 in some urgent or complex cases) described as
follows:
  • This will have been for a duration considered appropriate by the MDT (previous requirement was for 12-24 months). For patients with BMI > 50 attending a specialist obesity service, this period should include the stabilisation and assessment period prior to obesity surgery (previous requirement was a minimum of 6 months). Patients with new onset type 2 diabetes may have their surgical assessment concurrently with the medical tier 3 service.

Decision

Recommendation approved
Date of implementation: 28th November 2016
(no change to existing criteria)

 

Cosmetic surgery

Proposal

That the CCG no longer commission Cosmetic Surgery procedures:
• Breast Procedures – asymmetry / reduction / mastoplexy including revision / replacement
• Gynaecomastia
• Liposuction / skin contouring / body contouring
• Cosmetic Surgery

Funding for reconstructive surgery will continue, where this is not for cosmetic purposes.

Rationale

The CCG has a current financial deficit and is having to make decisions about ceasing funding of services and therefore has to review funding of all procedures of low/limited clinical value.

Impact

There should be limited impact on patients as these procedures are thought to be of low clinical value. Cosmetic surgery is a choice rather than a clinical need and should therefore be self-funded.
Efficiencies made will go towards the CCGs financial deficit position and work towards bringing the CCG back to its statutory requirement to achieve financial balance.

 Recommendation

The recommendation is:

  • The Board approves the general principles proposed for Cosmetic Surgery that procedures for Cosmetic reasons will not be funded

  • The Board approve the proposed criteria change for each condition:

                o Acne – resurfacing for severe post-acne facial scarring
                o Aesthetic facial surgery
                o Rhinoplasty
                o Body contouring
                o Breast procedures
                o Breast augmentation / breast reconstruction
                o Breast lift / mastoplexy
                o Breast reduction
                o Gynaecomastia
                o Hair depilation
                o Hymenorrhaphy
                o Laser treatment for tattoo removal
                o Liposuction / liposculpture / body contouring
                o Pinnaplasty / otoplasty
                o Plagiocephaly
                o Repair of ear lobes – post trauma
                o Rhinophyma
                o Scar revision – keloid
                o Scar revision – other
                o Septoplasty / septorhinoplasty
                o Vaginal labia refashioning

Decision

Recommendations approved
Implementation date: New referrals after 1st December 2016 will have to comply with the new criteria. Individuals booked for a date by 1st December 2016 will have the procedure carried out in line with the previous criteria as long as the procedure is complete by 30th June 2017 (no further procedure after this date)

 

Service Restriction Policy criteria changes

Purpose, brief description and overview

As part of the Fit For Future engagement, the CCG consulted on changes to current SRP criteria in addition two new areas for adding to the current policy.

The following chart shows those areas where changes have been made to the proposed criteria following public feedback and those where no change is required as a result of public engagement therefore the CCG intends to adopt the revised criteria.
Procedure Changes made to proposed criteria following consultation feedback
Benign skin lesion  Yes, in line with cosmetic surgery proposal
Carpal Tunnel  
Cataract  
Cholecystectomy
(gall stones)
 
Diagnostic Colonoscopy
for IBS
 
Dupuytren's Contracture  
Female Genital Prolapse  
Gastroscopy for dyspepsia   
 Hernia  
 Hip Arthoscopy  Yes,
  • Removed specialist physiotherapy replaced with MSK physiotherapy
Hysterectomy for Menorrhagia   
Knee Arthroscopy  
Knee Replacement  
Microsuction   
Shoulder Arthroscopy Yes. For the avoidance of doubt the CCG does not commission shoulder arthroscopy in the following:

• As a diagnostic tool
• For frozen shoulder or adhesive capsulitis – except in the circumstances outlined above.

The CCG will commission Shoulder arthroscopy as part of a procedural treatment i.e. as a less invasive surgical treatment but if used to treat adhesive capsulitis will only be funded if the above are criteria are met.
Sleep Studies  Yes,
  • Epworth score changed to 10 from 15
  • Criteria to specify obstructivesleep apnoea and snoring
Trigger Finger  
 Varicose  

Recommendation

 The Board is asked to approve the change in criteria and additions to the SRP following public engagement

Decision

Recommendation approved as per Fit for the Future board paper 24 November 2016
Implementation date: 1st December 2016