Policy number: SRP 004
Policy name: Low Clinical Priority Procedures
Status: Overarching commissioning policy
Effective date: 1 April 2024
Next review date: 1 April 2026
A number of procedures/treatments have been assessed as Low Clinical Priority by MSE ICB and will not be funded unless there are exceptional clinical circumstances.
Applications for funding for these procedures can be made through the IFR process but should only be made where the patient demonstrates clinical exceptionality.
In making a case for special consideration in relation to a restricted treatment on grounds of clinical exceptionality, it needs to be demonstrated that:
- The patient is significantly different from the general population of patients with the condition in question.
AND
- The patient is likely to gain significantly more benefit from the intervention than might normally be expected for patients with that condition.
Only evidence of clinical need will be considered. Factors such as gender, ethnicity, age, lifestyle or other social factors such as employment or parenthood cannot lawfully be taken into account.
It is not necessary to obtain a psychiatric opinion to support an application. MSE ICB expect mental health professionals to treat related problems through established services commissioned from the mental health trust(s) and this does not include surgery. The MSE ICB Exceptional Cases Panel consistently takes the view that psycho-social considerations should not be a justification for surgery. In such cases, psychological treatment such as counselling or cognitive behavioural therapy may be considered as an appropriate alternative to surgery. The effect of the problem on essential activities of day-to-day living is a key factor in decision-making.
Where referrers consider that there may be exceptional clinical circumstances, they must provide details of these exceptional clinical circumstances bearing in mind the points above.
Where indicated in the policy or where relevant, all individual funding requests, should be accompanied by suitable clinical photography that demonstrates the extent of the problem. This, of course, would be subject to patient consent.
Cosmetic surgery/treatments/interventions are not funded. Plastic surgery is only funded as detailed in policies or commissioned pathways e.g., as part of surgical management of trauma, serious congenital malformation. Post-surgical reconstruction is commissioned as per service level agreements for surgical services and in line with separate policies where in place.
Correction of privately funded treatments MSE ICB does not fund the correction of privately funded treatments cosmetic or otherwise. Where such treatments give rise to clinical problems, these will be managed through routine commissioned pathways and in line with any relevant commissioning policies.
Commissioning Policy This document has been written to be as complete as possible however it is not an exhaustive list. Providers must not assume that because a device or treatment/intervention/procedure is not included that by default it will be funded. MSE ICB commissioning position is that treatments not currently included in commissioned established care pathways (as identified for example in the Schedules to the service agreements with acute care providers) or identified for funding through the commissioning process are not routinely funded.