Policies and Guidance for CCGs in Hampshire

Clinical Commissioning Groups in Hampshire
Information and forms can be found by using the search facility on the right of the table below (just above Process Pathway). Type a word associated with the intervention you require and a limited list of policies and forms to be displayed. For example Assisted Conception would be displayed if any of the following is typed Assisted, Conception, IVF.

Fully completed application forms should be saved locally and sent from a secure NHS.net account to southcsu.ifrs@nhs.net for consideration.

INTERVENTIONPOLICY STATEMENT
(CURRENT POLICY, REFERRAL GUIDELINES)
PROCESS PATHWAY
(PATHWAY FOR TREATMENT AND APPROPRIATE FORMS)
Adenoidectomy in children with upper respiratory tract disorders
ENT
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
008 Adenoidectomy for children with recurrent upper respiratory tract infections - February 2016, Amendment April 2018
NEW


This procedure is not routinely funded except when offered in combination with Myringotomy (grommet insertion) and /or Tonsillectomy which require prior approval.

If there is exceptional health need for this procedure without myringotomy or tonsillectomy, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Appliances and devices for cosmetic purposes (high-grade silicon cosmeses and /or prostheses)
Plastic surgery
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Appliances and devices for cosmetic purposes (high-grade silicon cosmesis and /or prosthesis
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

Secondary Care IFR Form - Word format
Arthroscopic hip surgery in impingement
Orthopaedics/ MSK
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
006 Arthroscopic femoro-acetabular surgery for hip impingement - November 2015

This procedure is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Arthroscopic lavage and debridement with or without partial meniscectomy of the knee in patients with non-traumatic and persistent knee pain
Orthopaedics/ MSK
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
010 The place of arthroscopy in knee pain without true locking in adults over 40 years old - revised July 2018
NEW


Prior approval is not required for cases of traumatic knee pain.

In all other circumstances this procedure is not routinely funded and prior approval is always required from the IFR service. In the first instance, GP's to refer to the local MSK community service.

Requests are normally expected from Secondary Care or the MSK community service.

If MSK service wishes to refer to secondary care, or if a Consultant wishes to treat, they must fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Arthroscopic lavage and debridement for generalised non-traumatic and persistent knee pain form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Assisted conception
Infertility treatments
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
002 Assisted Conception Services - September 2014
Covers: NHS West Hampshire CCG, NHS North Hampshire CCG, NHS South East Hampshire CCG, NHS Portsmouth CCG, NHS Fareham and Gosport CCG, NHS Southampton City CCG

This procedure is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Referral for assisted conception - check list of eligibility form - Word format (not Farnahm CCG patients)

ivf-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Please note: Immigration health surcharge; removal of assisted conception services (Legislation.gov.uk)
Amendments to the NHS (Charges to Overseas Visitors) Regulations 2015 were introduced into Parliament on 19 July 2017. As a result, from 21 August 2017, assisted conception services will no longer be included in the scope of services available for free for those who pay the immigration health surcharge. It is therefore important that to ensure potential users of these services are aware of the changes.
Assisted conception
Infertility treatments
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Group's Priorities Committee
002 Assisted Conception Services - September 2014

Covering North East and Farnham CCG
Excluding GP Practices - Downing Street Surgery, River Wey Medical Practice, Farnham Dene Medical Practice, Holly Tree Surgery and The Ferns Medical Practice
This procedures is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Referral for assisted conception - check list of eligibility form - Word format for patients registered with North East and Farnham CCG

Please note: Immigration health surcharge; removal of assisted conception services (Legislation.gov.uk)
Amendments to the NHS (Charges to Overseas Visitors) Regulations 2015 were introduced into Parliament on 19 July 2017. As a result, from 21 August 2017, assisted conception services will no longer be included in the scope of services available for free for those who pay the immigration health surcharge. It is therefore important that to ensure potential users of these services are aware of the changes.
Assisted conception
Infertility treatments
Procedure that requires Prior Approval
NHS Surrey Assisted Conception Policy - February 2012
Covering only Farnham GP Practices - Downing Street Surgery, River Wey Medical Practice, Farnham Dene Medical Practice, Holly Tree Surgery and The Ferns Medical Practice
This procedures is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Referral for assisted conception - Check list of eligibility form - Word format for patients registered with a Farnham GP Surgery

Please note: Immigration health surcharge; removal of assisted conception services (Legislation.gov.uk)
Amendments to the NHS (Charges to Overseas Visitors) Regulations 2015 were introduced into Parliament on 19 July 2017. As a result, from 21 August 2017, assisted conception services will no longer be included in the scope of services available for free for those who pay the immigration health surcharge. It is therefore important that to ensure potential users of these services are aware of the changes.
Autologous Blood Injections for Musculoskeletal Conditions

Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Group's Priorities
024 Use of Autologous Blood Injections for Musculoskeletal Conditions - December 2017
NEW
This procedure is not routinely funded and prior approval is always required from the IFR service Pror to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

If there is exceptional health need, please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Balloon catheter sinus dilation for chronic rhinosinusitis
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
018 Balloon Catheter Sinus Dilation for Chronic Rhinosinusitis - February 2017
This procedure is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Bariatric SurgerySHIP8 Clinical Commissioning Groups' Priorities Committee
013 Bariatric Surgery procedures in severely obese adults who have failed to respond to lifestyle and tier 3 interventions - June 2016
For information only.
Bariatric Surgery RevisionSHIP8 Clinical Commissioning Groups' Priorities Committee
31 Bariatric Surgery Revision - April 2018
NEW
For information only.
Biologic therapy in the Management of Psoriasis - Sequential use and Dose EscalationSHIP8 Clinical Commissioning Groups' Priorities Committee
35 Sequential use and Dose Escalation of Biologic therapy in the Management of Psoriasis - June 2018
NEW
For information only.
Bone morphogenetic Protein and low-intensity pulsed ultrasound in delayed and non-union fractures(Exogen)
Procedure Not Routinely Funded
South Central Priorities Committee
(Southampton, Hampshire, Isle of Wight and Portsmouth PCTs)
139 Bone morphogenetic protein and low-intensity pulsed ultrasound in delayed and non-union fractures - August 2012
This procedure is not routinely funded and prior approval is always required from the IFR service.

If there is exceptional health need for this procedure please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Bunions (hallux valgus)
Orthopaedics/ MSK
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Treatment of bunions (hallux valgus)
This procedure is not routinely funded and in the first instance, GP's to refer to the local MSK community service.

Requests are normally expected from Secondary Care or the MSK community service.

If MSK service wishes to refer to secondary care, or if a Consultant wishes to treat, they must fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Hallux valgus (bunions) form - Word format
Bursledon House - Assessment and admission for in-patient treatment
Children’s Services
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Assessment and admission to Bursledon House in Southampton for in-patient treatment
This treatment is not routinely funded and prior approval is always required from the IFR service.

If there is exceptional health need please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

Secondary Care IFR Form - Word format
Carpal tunnel release/ nerve entrapment at wrist
Orthopaedics/ MSK
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
22 Carpal Tunnel - August 2017
This procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Primary Care, Secondary Care or MSK service.

Please fully complete the following appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Carpal tunnel release Form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Cataract RemovalSHIP8 Clinical Commissioning Groups' Priorities Committee
32 Cataract Removal - April 2018
NEW
For information only.
Cholecystectomy - Asymptomatic GallstonesSHIP8 Clinical Commissioning Groups' Priorities Committee
012 Cholecystectomy for patients with asymptomatic gallstones - April 2018
NEW
For information only.
Chronic Anal Fissure (CAF) in Adults
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
025 Treatment of Chronic Anal Fissure (CAF) in Adults - December 2017
NEW
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Requests are normally expected from Secondary Care

Please fully complete the following form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Chronic Anal Fissure (CAF) in Adults form - Word format

Chronic Fatigue Syndrome(CFS)/ Myalgic Encephalomyelitis(ME) - inpatient treatment
Mental health
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
In patient treatment for severe chronic Fatigue/ME in patient treatment
This treatment is not routinely funded. Severe cases require prior approval from the IFR service prior to referral and treatment but Mild-to-Moderate cases are available within the commissioned outpatient service run by South Coast Fatigue.

For severe cases a strong case on grounds of exceptional health need must be provided. If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

Secondary Care IFR Form - Word format
Complementary therapies/medicine
Alternative/
complementary/ homeopathic therapies
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Complementary therapies/medicine
This treatment is not routinely funded as a separate procedure but can be used without prior approval when included as an adjunct to usual therapy e.g. acupuncture within physiotherapy or pain management services. Not funded as a separate procedure

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

Secondary Care IFR Form - Word format.
Continuous glucose monitoring (CGM) for adults with Type 1 Diabetes Mellitus
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
007 Continuous Glucose Monitoring (CGM) for adults with Type 1 Diabetes Mellitus - February 2016
This treatment is not routinely funded for patients requiring Continuous Glucose Monitoring (CGM) without the use of pump therapy.

Applications are expected from Secondary Care/Diabetes Specialists.

For these cases a strong case on grounds of exceptional health need must be provided. If there is exceptional health need, please complete fully the following form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Secondary Care IFR Form - Word format
Cryopreservation - preservation of fertility (Male and Female)
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
30 Cryopreservation optins for patients about to start NHS treatment which might impair their future fertility - April 2018
NEW
This procedure is not routinely funded and prior approval is always required from the IFR service.

Requests are normally expected from Secondary Care.

If Secondary Care/Consultant wishes to treat, they must provide details of the diagnosis, prospective treatment and evidence of how this may impair future fertility. Please email this to southcsu.ifrs@nhs.net for consideration.
Dupuytren’s contracture / Palmar fasciectomy
Orthopaedics/ MSK
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Palmar fasciectomy /Dupuytren’s contracture
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment in secondary care.

Requests are normally expected from Primary Care or MSK community service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Palmar fasciectomy for Dupuytren’s Contracture Form - Word format
Excision of skin following massive weight loss
including abdominoplasty, mammoplasty and removal of skin folds from the inner thighs
Cosmetic/Plastic/ Aesthetic surgery
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Excision of skin following massive weight loss
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Requests are normally expected from Primary care

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Skin reduction surgery after massive weight loss form - Word format
Eyelid Surgery
Ophthalmology
Procedure that requires Prior Approval

including Blepharoplasty, Chalazia (meibomian cysts), Ectropion/ Entropion, Ptosis & Dermatochalasis
IFR Policies and Procedure extracts:
Eyelid Surgery
NHS South East Hampshire, NHS Portsmouth, NHS Fareham & Gosport CCGs

Eyelid Surgery
NHS West Hampshire and NHS North Hampshire CCGs
Where there is a suspicion of malignancy, the patient is referred using a two-week wait referral form for suspected cancer.

In all other circumstances this procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment in secondary care.

Requests are normally expected from Primary Care.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Eye Lid Surgery Form - Word format
Faecal microbiota transplants

- Recurrent or refractory C. difficile infection up to a maximum of two transplants
Procedure Funded Subject to Audit

- For all other indications
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
017 Faecal Microbiota Transplants - February 2017
Faecal Microbiota Transplants are commissioned for recurrent or refractory C. difficile infection up to a maximum of two transplants. Prior approval is not required from the IFR service if the policy criteria outlined in the policy are met.

All other indications are not routinely funded and prior approval is always required from the IFR service. If the Consultant wishes to treat outside of policy please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Female sterilisation
Gynaecology
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Female Sterilisation
This procedure is not routinely funded and prior approval is always required from the IFR service prior to treatment.

Requests are normally expected from Primary Care or Gynaecology Service.

Please fully complete the following appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Female Sterilisation Form - Word format
'Flash' Glucose Monitoring in Diabetes
SHIP8 Clinical Commissioning Groups' Priorities Committee
028 'Flash' Glucose monitoring in Diabetes - January 2018
NEW
For notification only.

Providers are expected to keep a record of all patients set up with a Flash glucose monitor in line with the criteria and this should be reported with CCG medicines management teams.
Flexible Sigmoidoscopy
- Suspected Colorectal Cancer
SHIP8 Clinical Commissioning Groups' Priorities Committee
011 Flexible Sigmoidoscopy in Suspected Colorectal Cancer - April 2016
For information only.
Functional electrical stimulation (FES) in drop foot
Other services
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
005 Functional electrical stimulation in the management of drop foot of central neurological origin (specifically post stroke and multiple sclerosis) - July 2015
Prior approval must be obtained before assessment and treatment from the IFR service. Functional Electrical Stimulation may be considered as a second line treatment option for carefully selected patients with drop foot (most commonly due to multiple sclerosis or stroke).

Please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Prior Approval Functional Electrical Stimulation form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Functional endoscopic sinus surgery
ENT/ Audiology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
019 Functional endoscopic sinus surgery for chronic rhinosinusitis and nasal polyps - February 2017
Prior approval is required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary evidence, email it to email it to southcsu.ifrs@nhs.net for consideration.

Functional endoscopic sinus surgery form - Word Format
Functional nasal airways surgery (which may include septo-rhinoplasty)
ENT/ Audiology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
23 Functional Nasal Airways Surgery - August 2017

Emergency procedures recorded under admission 21-28 do not require prior approval.

In all other cases this procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Primary Care or ENT.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Functional nasal airways surgery form

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Ganglion Surgery
General surgery/ hand surgery/
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Treatment of ganglions
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment in Secondary Care.

Requests are normally expected from Primary Care.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Ganglion Form - Word format
Gastric fundoplication for chronic reflux oesophagitis
Gastroenterology
Procedure that requires Prior Approval
South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
51 - Laparoscopic fundoplication for chronic reflux - November 2009
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment for this indication.

Application is expected from secondary care

If the Consultant wishes to treat please fully complete the following appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Gastric fundoplication for reflux oesophagitis form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Hip resurfacing
Orthopaedics/MSK
Procedure that requires Prior Approval
South Central Priorities Committee
(Southampton, Hampshire, Isle of Wight and Portsmouth PCTs)
105 Metal on metal hip resurfacing - April 2011

This procedure is not routinely funded for older men (over 55) or for women of any age. Prior approval is always required from the IFR service prior to referral and treatment in secondary care.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Hip Resurfacing Form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Hydrocele
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities
026 Treatment of Hydrocele - December 2017
NEW
Covers: NHS South East Hampshire CCG, NHS Portsmouth CCG, NHS Fareham and Gosport CCG
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Requests are normally expected from Secondary Care

Please fully complete the following form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Treatment of Hydrocele Form - Word format
Hysterectomy in heavy menstrual bleeding/ dysmennorhea (menorrhagia)
Gynaecology
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Hysterectomy in heavy menstrual bleeding/ dysmennorhea
Hysterectomy for uterine problems amenable to surgery and not related to heavy menstrual bleeding or dysmenorrhoea will be funded and do not require prior approval.

In all other circumstances this procedure is not routinely funded and prior approval is always required from the IFR service.

Requests are normally expected from Secondary Care.

If the Consultant wishes to treat please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Hysterectomy for Menorrhagia Form - Word format
Inguinal hernia - Asymptomatic
General surgery/ hand surgery
Procedure that requires Prior Approval
South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
148 Repair of asymptomatic inguinal hernias in adults - February 2013
Emergency procedures recorded under admission 21-28 do not require prior approval

In all other cases this procedure is not routinely funded and prior approval is always required from the IFR service.

Requests are normally expected from Secondary Care.

If a Consultant wishes to treat please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Asymptomatic inguinal hernia form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Interventional treatments for back pain (spinal/epidural injections; facet joint and medial branch blocks; radio-frequency lesioning/ denervation)
Pain Management
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
20 Overall Pathway of Back Pain Management - April 2017
NEW
This procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Secondary Care.

If the Consultant wishes to treat please fully complete the following appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Interventional treatments for back neck pain form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Laser therapy for recurrent pilonidal sinus
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
016 Laser Therapy for recurrent Pilonidal Sinus - February 2017
This procedure is not routinely funded and prior approval is always required from the IFR service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Laser treatment
including
Removal of skin
Excessive hirsutism
Surgical shaving
Chemical destruction of skin
Plastic surgery
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Laser removal of skin and excessive hirsutism
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Primary Care.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

Secondary Care IFR Form - Word format
Liothyronine in the treatment of Primary HypothyroidismSHIP8 Clinical Commissioning Groups' Priorities Committee
027 Liothyronine in the treatment of Primary Hypothyroidism - January 2018
NEW
For information only.
Lymphoedema - Intensive decongestive therapy
Other services
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
004 Treatments for patients with lymphoedema - June 2015
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Prior Approval Lymphoedema Form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.
Male circumcision
Urology
Procedure that requires Prior Approval
IFR Policies and Procedure extracts:
Male Circumcision
NHS West Hampshire and NHS North Hampshire CCGs

Male Circumcision
NHS Fareham & Gosport, NHS South East Hampshire and NHS Portsmouth CCGs
Where there is a suspicion of malignancy, the patient should be referred using the two-week wait referral form.

In all other cases this procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Secondary Care and Primary Care

If the GP wishes to refer or the Consultant wishes to treat please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

NHS West Hampshire and NHS North Hampshire CCGs
Male Circumcision Form - Word format

NHS Fareham & Gosport, NHS South East Hampshire and NHS Portmouth CCGs
Male Circumcision Form - Word format
Microsuction for the removal of ear wax in adults of 16 yeasrs and over.SHIP8 Clinical Commissioning Groups' Priorities Committee
33 Microsuction for the removal of ear wax in adults of 16 years and over - June 2018
NEW
For information only.
Myringotomy/ grommet insertion for adults
ENT/Audiology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
37 Grommet insertion - adults and children - July 2018
NEW

This procedure is not routinely funded and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Secondary Care.

If the Consultant wishes to treat please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Grommets insertion (myringotomy) in Adults Form - Word format
Myringotomy/ grommet insertion for children
ENT/Audiology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
37 Grommet insertion - adults and children - July 2018
NEW
Children under 3 years of age may be treated without prior approval.

This procedure is not routinely funded in all other circumstances and prior approval must be obtained before treatment from the IFR service.

Requests are normally expected from Secondary Care.

If the Consultant wishes to treat please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Grommets insertion (myringotomy) in Children Form - Word format
Non-Alcoholic Fatty Liver DiseaseSHIP8 Clinical Commissioning Groups' Priorities Committee
038 Non-Alcoholic Fatty Liver Disease - July 2018
NEW
For information only.
Non-NHS residential placements
Mental health
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Non-NHS residential placements
This treatment is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

Secondary Care IFR Form - Word format
Obstructive Sleep Apnoes - Diagnosis using Pulse Oximetry SHIP8 Clinical Commissioning Groups' Priorities Committee
34 Pulse Oximetry for the diagnosis of Obstructive Sleep Apnoea - June 2018
NEW
For information only.
Orthodontics for those over 18 years of age
Dental
Wessex Area Team: Procedure Not Routinely Funded
NHS England - Wessex Area Team
Orthodontic over 18 - May 2013
The NHS does not routinely fund orthodontic treatment in adults and it is the responsibility of the patient to maintain any long-term retainers when they reach 18.

For under 18s General Dental Practitioners should use the Orthodontic Central Referral Centre.

If there is exceptional health need, the General Dental Practitioner seeking orthodontic treatment must complete fully the following form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.
Orthodontic form - Over 18's - Word format
Partial Knee Arthroplasty inpatients with Osteoarthritis of the kneeSHIP8 Clinical Commissioning Groups' Priorities Committee
003 The Use of Partial Knee Arthroplasty in patients with Osteoarthritis of Knee - April 2015
For information only.
Patella Resurfacing in knee replacement
Orthopaedics/ MSK
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
015 Patellar resurfacing as part of primary total knee joint replacement - August 2016
This procedure is not routinely fundined and prior approval is always required from the IFR service.

Requests are normally expected from Secondary Care or the MSK community service.
Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
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Secondary Care IFR Form - Word format
Pelvic Organ Prolapse
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
029 Surgical management of pelvic organ prolapse - June 2018
NEW
This is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Pelvic Organ Prolapse Form - Word format
Penile prosthesis for erectile dysfunction
Procedure Not Routinely Funded
South Central Priorities Committee
(Southampton, Hampshire, Isle of Wight and Portsmouth PCTs)
96a Evaluation of treatments for erectile dysfunction - February 2011, amended July 2011
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Secondary Care

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Plastic/Cosmetic procedures
including:
Abdominoplasty
Buttock lift, thigh lift, upper arm lift (brachioplasty)
Facelift
Female cosmetic genital surgery (labiaplasty)
Implant removal and replacement
Liposuction
Pinnaplasty/meatoplasty/plastic operations on external ear
Rhinoplasty/reconstruction of nose
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Plastic/cosmetic procedures surgery

South Central Priorities Committee
(Southampton, Hampshire, Isle of Wight and Portsmouth PCTs)
121 - Aesthetic surgery in children - Dec 2011

Guidance Notes
Policy and Procedure for Individual Funding Requests - Appendix 6
These procedures are not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Primary Care.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

Secondary Care IFR Form - Word format
Plastic/Cosmetic procedures
including:
Breast and nipple procedures
Breast augmentation
Breast reduction
Gynaecomastia
Implant removal and replacement
Mastopexy
Procedure Not Routinely Funded
IFR Policies and Procedure Statement: Appendix 1 -
Breast and nipple procedures

South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
15 Cosmetic breast surgery - Sept 2008

Guidance Notes
Policy and Procedure for Individual Funding Requests - Appendix 6
Reconstructive procedures may go ahead as part of established pathways and must take place within one year of the last cancer treatment.

Outside of the above exclusion these procedures are not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Primary Care.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Primary hip and knee replacement in patients with a BMI above 35
Orthopaedics/ MSK
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Primary hip and knee replacement in patients with a BMI above 35
Emergency procedures recorded under admission 21-28 do not require prior approval.

In all other cases this procedure is not routinely funded and prior approval is always required from the IFR service. Referrals should have been made to the commissioned tier 2 or tier 3 obesity management programme prior to offering surgery.

If MSK wishes to refer to secondary care, or if a Consultant wishes to treat, please fully complete the following appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Hip or Knee Replacement in Obese Patients Form - Word format
Primary hip or knee replacement surgery - routine follow-up
Orthopaedics
Procedure Not Routinely Funded
South Central Priorities Committee
(Hampshire & Isle of Wight PCTs)
110 Routine follow up after primary hip or knee replacement surgery - August 2011
Following the initial routine follow-up appointment, further follow-up appointments are not normally funded and wll be challenged via the contract.
Restorative dental including:
Dental implants
Endodontics
Periodontal treatment
Specialised Prosthodontic treatment (fixed and removable)
Wessex Area Team: Procedure Not Routinely Funded
NHS England - Wessex Area Team
Advanced Restorative Dentistry - April 2013 Interim Policy

Provision of Dental Implants - May 2013

Specialist Endodontic Treatment - May 2013

Specialist Periodontal Treatment - June 2014
This policy covers access to specialist input for periodontal (gum) disease. Full compliance with oral hygiene and non-smoking status are essential as well as every effort made in primary care to manage the problem.

Specialist Fixed Prosthodontic Treatment - May 2013

Removable Prosthodontics - May 2013
This covers specialist input for removable prosthodontics
For dental referrals of patients registered at GP practices within the Southampton, Hampshire, Isle of Wight, Portsmouth, Bournemouth, Poole and Dorset local authority areas.

Patients registered with a Farnham GP practice are outside the responsibility of the Wessex Area Team. Please contact the Surrey & Sussex Area Team regarding dental referrals

If there is exceptional health need, please fully complete sections 1 to 3 and section 5. Then complete the relevant part of section 4 relating to the specialty to which you are referring.
Dental IFR form - Word format
Email the completed form with all relevant documentary proof to southcsu.ifrs@nhs.net for consideration.
Reversal of sterilisation/ vasectomy
Urology
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Reversal of sterilisation/ vasectomy
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment. For these cases a strong case on grounds of exceptional health need must be provided.

Requests are normally expected from Primary Care
If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

Secondary Care IFR Form - Word format
Second eye cataract surgery
Ophthalmology
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Second eye cataract surgery
NHS Portsmouth, NHS Farenham & Gosport, NHS South East Hampshire CCGs
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment in secondary care.

Requests are normally expected from Primary care or community optometry services. Requests from secondary care ophthalmology should only involve patients on long-term follow-up or listed for bilateral two-stage procedures.

Please complete the following form and submit with the relevant documentary evidence to southcsu.ifrs@nhs.net for consideration.

Cataract Surgery in Second Eye Form - Word format
Short sight/long sight corrective (laser) surgery (Refractive keratoplasty)
Ophthalmology
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Short sight/long sight corrective (laser) surgery (Refractive keratoplasty)
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Requests are normally expected from Secondary care.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Secondary Care IFR Form - Word format
Subacromial decompression of the shoulder
Orthopaedics/ MSK
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
014 Subacromial decompression of the shoulder - June 2016
This procedure is not routinely funded and prior approval is always required from the IFR service. In the first instance, GP's to refer to the local MSK community service.

Requests are normally expected from Secondary Care or the MSK community service.

Please fully complete the following form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Subacromial shoulder decompression form - Word format
Surgery for snoring
ENT
Procedure Not Routinely Funded
SHIP8 Clinical Commissioning Groups' Priorities Committee
009 Treatments for people who snore - February 2016
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

If there is exceptional health need, please complete fully the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Primary Care IFR Form - Word format

ifr-referral-form-v042015 - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

Secondary Care IFR Form - Word format
Surgical removal of skin lesions
Dermatology/general surgery
Procedure Not Routinely Funded
IFR Policies and Procedure extract:
Surgical removal of skin lesions
NHS Portsmouth, NHS Fareham & Gosport, NHS South East Hampshire CCGs
If there is a suspicion of malignancy, the patient should be referred using the two-week wait referral form for suspected cancer or via the local BCC fast track pathway. Where the treatment is for Hidradenitis suppurutiva then prior approval is not required.

Outside of the above exclusion this procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Requests are normally expected from Primary Care.

If there is exceptional health need, please complete fully the appropriate form, the Dermatolgoy Life Quality Index and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Skin Lesions Form - Word format

Dermatology Life Quality Index - Adult
Dermatology Life Quality Index - Child
Tonsillectomy
ENT/ Audiology
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
36 Tonsillectomy - adults and children - July 2018
NEW
Prior approval is not required for patients who have been referred via the two-week wait referral form for suspected cancer.

In all other circumstances prior approval must be obtained from the IFR service before treatment.

Requests are normally expected from Primary Care or ENT.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.


Tonsillectomy Form - Word format
Trigger finger surgery
Orthopaedics/ MSK
Procedure that requires Prior Approval
IFR Policies and Procedure extract:
Trigger finger surgery
This procedure is not routinely funded and prior approval is always required from the IFR service prior to referral and treatment.

Requests are normally expected from Primary Care or MSK community service.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Trigger Finger Surgery Form - Word format
Varicose vein procedures
Vascular Surgery
Procedure that requires Prior Approval
SHIP8 Clinical Commissioning Groups' Priorities Committee
001 Interventional procedures for varicose veins - August 2014
Emergency procedures recorded under admission 21-28 do not require prior approval.

In all other circumstances this procedure is not routinely funded and prior approval must be obtained from the IFR service before referral and treatment in secondary care.

Requests normally are expected from Primary Care.

Please fully complete the appropriate form and together with all relevant documentary proof, email it to southcsu.ifrs@nhs.net for consideration.

Varicose Veins Treatment Form - Word format

prior-approval-application-form - Emis Web forms
To import this into Emis web: Save the form onto your drive. In Emis Web Template Manager, Document Templates tab, create or select a folder, then click Import from the ribbon bar. Navigate to the location you have saved the file and it should import ready to use. Please note you will not be able to open the file outside of Emis Web.

 

For more information
Please email the IFR service at southcsu.ifrs@nhs.net for all enquiries about the policy statements or the process for considering Individual Funding Requests.