Visual refractive error is a common eye condition. It causes what people see to become blurred and often become what is known as short-sighted, long-sighted or astigmatism.

It is usually treated using glasses or contact lenses.

Photorefractive surgery (PRS), is also known as laser eye surgery. The procedure uses lasers to remove part of the cornea (part of the eye) that then grows back correcting the issue.

The policy aims to manage inappropriate referral and procedure activity in line with evidence-based best practice.

Currently, NHS Lancashire & South Cumbria ICB does not fund the procedure.

The current policy can be found here:

https://www.healthierlsc.co.uk/download_file/view/7364/14404

The new policy says the ICB will still not routinely fund the procedure but allows one exception. It will be allowed for people who have a refractive error caused by other eye surgery or after a cornea transplant IF the problem is not solved by using glasses or contact lenses.

Overall, this should mean that more people are able to have the surgery but still only when it is absolutely necessary.

You can read the full new wording below:

New wording in full:

1. The ICB does not routinely commission photorefractive surgery for the correction of refractive error  

An additional exclusion should be added as follows: 

Patients who have a refractive error arising from non-refractive ophthalmic surgery or corneal transplantation, and whose refractive error cannot be corrected by the use of glasses or contact lenses, are excluded from this policy. 

Click here to take the questionnaire.

Hip and knee replacements are common NHS operations. They replace a worn or damaged hip or knee joint with an artificial joint (a new “man made” part). This new joint is usually made from metal, plastic, or ceramic.

The operation is done to reduce severe pain and help people move better, often when the smooth covering in the joint has worn away. It is done in hospital, usually with a general anaesthetic (you are asleep). The operation often takes about 1 to 1.5 hours. Many people go home the same day or soon after. Getting fully better can take several months. The new joint is usually made to last about 15 to 25 years.

Doctors usually try other treatments first, especially for hip arthritis. This can include pain relief, advice about the condition, exercises, and staying as active as possible. These can help some people and may delay surgery for a long time. If the joint is badly damaged, a full hip replacement can be one of the best treatments. For most people, the risks from these operations are small.

Some studies have looked at how a high BMI (being very overweight) affects hip or knee replacement. Overall, the evidence suggests a high BMI can increase some risks during or after surgery, especially infection. But the long term results are usually similar for people with higher and lower BMI.

At the moment, NHS Lancashire and South Cumbria ICB does not have a specific policy just for hip and knee replacement surgery. Other nearby ICBs, like Greater Manchester and Cheshire and Merseyside, already have policies for this surgery. Having a policy for Lancashire and South Cumbria would help us match what other areas do and make decisions more consistent.

The new policy says the operation will be routinely commissioned under certain circumstances.

These are:

• The symptoms (eg pain) have a substantial impact on quality of life
• Symptoms have lasted at least three months even though other treatments such as special exercises have been tried. 
• The need is confirmed with radiography (x-ray)
• Patients must be given advice on lifestyle changes after the operation and the patient and clinician must decide together the operation is the right thing to do

Plus some others. There are some exceptions where some people wont have to meet the above criteria. These are mostly people who have already had a hip or knee replacement operation.

New wording in full:
Joint replacement (arthroplasty) surgery for hip or knee is routinely commissioned if all of the statements (1 - 4) are satisfied. 

1. For each patient, all of the following criteria must be satisfied:- 

• Patient’s symptoms (pain, stiffness, reduced function or progressive joint deformity) are having a substantial impact on their quality-of-life 
• Symptoms persist despite at least a 3 months’ trial of conservative measures (such as analgesics, prescribed exercises) 
• There is radiographic confirmation of diagnosis. 

2. Patients are given advice on preoperative lifestyle modifications (e.g. exercise, weight management, diet and smoking cessation) 

3. The decision to go ahead with surgery follows a shared decision-making process between the patient and clinician following a discussion regarding the alternatives, benefits & risks and provision of appropriate information. 

4. Patient specific factors such as age, sex, smoking, overweight or obesity and comorbidities should not be barriers to referral. The impact of these on surgical outcome should be explained to the patient. 

5. Patient specific instrumentation techniques are not routinely commissioned unless the case is complex, conventional instrumentation is unsuitable, and its use has been approved by a local or regional multidisciplinary team (MDT) for that individual. 

6. Custom (patient specific) implants are not routinely commissioned unless the case is complex, and its use has been approved by a local or regional multidisciplinary team (MDT) for that individual. 

Exclusions 

1. Patients undergoing revision of a previous joint replacement are excluded from this commissioning statement. 
2. Patients with previous surgery on the joint are excluded from this commissioning statement
3. Patients with rapidly progressing deterioration over a few weeks or have red flag warning signs for bony metastases* are excluded from this commissioning statement and require urgent referral. 
4. Children and young adults under the age of 17 years are outside the remit of this commissioning statement.

* Red flag symptoms for cancer-related bone pain included severe progressive pain that is worse on movement or at night, inability to bear weight, signs of hypercalcaemia, and pain on direct palpation. 

Click here to complete the questionnaire.

Cataract surgery is an operation to replace a cloudy lens in your eye with an artificial lens.

Cataract surgery is done to improve your vision if you have cataracts. Cataract is a very common condition mostly affecting older people.

Cataract is where the lens in your eye becomes cloudy, which can cause blurry vision and loss of sight. It mainly affects older adults (age-related cataracts) but can also affect children (childhood cataracts).

Surgery is the only way to get rid of cataracts.

There is currently no published clinical policy for cataract surgery within Lancashire and South Cumbria ICB. Neighbouring ICBs, including Greater Manchester and Cheshire & Merseyside, have established policy positions in place. Adopting a cataract policy for the LSC area would support greater alignment with regional ICBs and promote consistency in commissioning practice.

The new policy says that Cataract surgery is routinely commissioned, for patients that are fit for surgery and consent to it, if some criteria are satisfied. In summary these are:

• An assessment of the patient’s eyesight suggests surgery is appropriate
• If there is significant imbalance of vision that is getting worse
• The person has a condition called glaucoma or wet macular degeneration
• The person has with diabetes

The policy follows NICE guidance.

New wording in full

1. Cataract surgery is routinely commissioned if any of the criteria listed below are satisfied:

• An assessment of the patient’s visual quality of life (using the assessment template below) suggests surgery is appropriate

or

• Significant ocular imbalance (anisometropia) due to progression of an existing cataract or following cataract surgery on the first eye

or

• Patients with glaucoma who require cataract surgery to control intra ocular pressure

or

• Patients with diabetes who require clear views of their retina to look for retinopathy

or

• Patients with wet macular degeneration or other retinal conditions who require clear views of their retina to monitor their disease or treatment (e.g. treatment with anti-VEGFs).

AND

2. For ALL cases, the following additional criteria (see Final Checklist below) are also satisfied:

• Fitness for surgery is considered to be adequate

AND

• Patient consent is given (when fully informed of the likely benefits and risks)

Template to assess the visual quality of life

(As an opening question, it is useful to ask the patient whether there are any activities which they used to do in the past, which they would be keen to do again, but their poor vision is stopping them. This gives an initial impression which should then be supplemented by asking the detailed questions below)

Questions

Response A

Response B

Response C

1. How well can the patient see objects in the distance when wearing the appropriate spectacles?

Without difficulty

With slight difficulty

With great difficulty

2. How well can the patient see writing on the TV and/or road signs when wearing the appropriate spectacles?

Without difficulty

With slight difficulty

With great difficulty

3. How well can the patient recognise people on the street at a distance when wearing the appropriate spectacles?

Without difficulty

With slight difficulty

With great difficulty

4. How well can the patient see the text in a newspaper, book or screen when wearing the appropriate spectacles?

Without difficulty

With slight difficulty

With great difficulty

5. How often does the patient experience glare when it is sunny, or experience light scatter from lights at night, to the point that they find it uncomfortable or difficult to function normally as a result?

Without difficulty

With slight difficulty

With great difficulty

Click here to complete the questionnaire.

Bunions are bony lumps that form on the side of the feet.

The skin may be damaged in the area of the bunion causing pain on walking, difficulty with footwear and concerns about its appearance. In some cases, they may cause people to struggle with their balance.

They can be much worse and lead to additional complications for people with diabetes.

This is a new clinical policy across the Lancashire and South Cumbria ICB footprint. There was a previous policy that covered the former CCG area in Greater Preston but this was not updated when the previous eight CCGs in Lancashire and South Cumbria were abolished in 2022 and the ICB was formed.

The proposed policy is currently in force within Cheshire and Merseyside ICB.

Under the new policy the surgical removal of bunions is not routinely funded. A patient can however be referred for a surgical opinion (which may lead to the surgery being undertaken) if other treatments have not worked when tried for at least three months AND they have pain or the bunion is causing a disability.

New wording in full:

Surgical removal of bunions (hallux valgus) is not routinely commissioned for cosmetic reasons alone.

Patients may be referred for a surgical opinion if all of the following criteria have been satisfied:

• They have failed to respond to at least 3 months of conservative treatments. (These include footwear modification, bunion pads, insoles, simple analgesics, orthotics, physiotherapy).

AND

• Experience pain under the ball of the foot and/or functional disability.

Click here to complete the questionnaire.