i live in nf. canada.how does one proceed to obtain an apronectomy and how do you qualify?

Answer 1

This will give you a brief outlook:

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Approval process to access non-routine or restricted services – current arrangements

Over a number of years various policies have been developed to manage demand for non-routine or limited services in a way that is as equitable as possible, without imposing a blanket ban. Over that time, there has been a lot of organisational change and this document is written for practitioners, to summarise the current arrangements for approving access in such circumstances. This document does not alter most existing policy; it restates the current position. However, in the light of NICE guidelines on access to IVF, slight changes are being made to eligibility criteria. These are highlighted later in the document.

Restricted access

For a number of years access has been restricted to particular services because of demand exceeding the capacity of the service. The two main areas that result in difficulty are cosmetic surgery and treatment for infertility.
Cosmetic surgery

There is no access to cosmetic surgery other than in exceptional circumstances. The position on cosmetic surgery was developed with other commissioning organisations and service providers several years ago because of the increasing demand for plastic surgery. In trying to be consistent across a wider patch, a summary was produced to describe the sort of circumstances that might be considered exceptional. This document is found at appendix 1. The process for referral is detailed later in this document (see Approval process).

Over time, there were increasing numbers of referrals for breast reduction surgery. These procedures were problematic because each case occupied a full operating list. Guidance and a referral form were produced to standardise the threshold for referring cases, to ensure appropriate referrals and to check that all appropriate interventions had been tried and failed before referring for surgery. The documentation relating to this procedure is found at appendix 2.

Where psychological or physical difficulties are cited as the justification for the proposed intervention, all efforts should have been made already to manage these problems. Using a psychological assessment as a hurdle is inappropriate and a waste of resources. Where physical characteristics fall within the range considered normal in the population, an assessment that indicates someone might be happier if their request for cosmetic surgery were approved, would not in itself justify consideration as exceptional circumstances. It is expected that appropriate interventions to improve psychological well-being would have been used over a period of time before surgery would ever be considered as an option. Similarly, where physical symptoms such as neck or back pain are the reasons for considering surgery (such as breast reduction), all other appropriate interventions should have been tried and failed. Documentation of such efforts will be expected for any potential referrals.
Infertility

The local policy on treatment for infertility was developed some years ago in consultation with clinicians in primary, secondary and specialist care and with service users. Given the demand for access to assisted conception treatment, the guidelines attempted to balance evidence of effectiveness with fairness. They therefore incorporated both physiological and social criteria relating to patients, and specified a service provider.

Referral criteria up till now are:

* a minimum duration of 3 years unexplained infertility
* the female partner aged 35 years or less at the time of treatment
* no history of failed sterilisation reversal in either male or female partner
* no other living children in this or any previous relationships for either partner.

Referrals are managed via the service run by Professor Alison Murdoch, based at the Centre for Life in Newcastle. All prescribing of drugs should be done through the IVF service, since these have been funded already. There should be no need for prescribing in primary care. The existing agreement is to provide 2 cycles of NHS treatment for eligible couples. Exceptions to the criteria are considered, and there is a formal mechanism for this (see Approval process).

The recent publication of NICE guidelines on the management of infertility, and the subsequent guidance from the DOH mean that the age cut off will have to increase by April 2005. By that point we are required to offer one cycle of IVF to all eligible women aged up to 39 rather than up to the current 35 years. Social criteria were not included in the NICE guideline, but the DOH statement includes an expectation that priority would be given to families with no children living with them. Plans for implementation will be developed over the coming year. It is likely that changes will be phased over time.

However, in the meantime, the age limit for treatment is to be increased to 39 years, but only one cycle of IVF will be offered to each woman. There is no change to the social criteria outlined above. Where a woman has already commenced treatment and been told she will be eligible for two cycles of treatment, this will be honoured.

This interim change in policy allows for the increased age range to be covered within existing resources. It is expected that the number of cycles available will be increased at a future date. Women who are offered one cycle under this amended policy would be eligible for more cycles in the future as the number of cycles increases (assuming that other criteria are still met).
Non-routine services

Occasionally patients need to be referred outside the normal range of services available locally because of the nature of their condition or particular personal circumstances. Sometimes these may be covered by service agreements set for specialist services at a regional or national level. At other times they will not. The service provider may require an agreement from the Care Trust to fund such referrals in advance. In such cases, there will usually be clear indications as to the need for referral, and these should be presented through the approval process as indicated below.


Approval process

The case should be submitted by the responsible practitioner to the appropriate locality director for consideration. Where criteria apply (for example, for access to IVF) the request should include a clear statement as to eligibility with respect to each criterion, in addition to a statement regarding whatever circumstances exist to indicate that the case should be considered exceptional. If there is a form to be completed (for example, breast reduction surgery), this should be submitted with the request. Where there is supporting documentation, it is helpful to present this at the same time.

The use of patient identifiers should be minimised. Requests should be anonymised where possible.

The locality director will provide a response to the referring clinician. If the outcome is unfavourable, and the patient wishes to appeal, there is a mechanism to do so. This is outlined below. If however new information became available at a future date that might reasonably be expected to influence the original decision, this could be submitted again at locality level with the additional information, and the case could be reconsidered.

When cases are approved, a copy of the approval letter should be sent with the clinical referral to avoid delay in offering appointments.
Appeal mechanism

If at initial consideration at locality level, an unfavourable opinion is given, and the patient is unhappy with the decision, an appeal can be made. The Director of Public Health convenes a panel to review such cases. The responsible clinician should write to the Director of Public Health outlining the reason for the appeal, enclosing all paperwork from the initial application and any other documentation felt to be helpful. As before, it is helpful to anonymise documents as far as possible for the panel, whilst ensuring that the case is identifiable in some way to clinical staff that may need to be contacted to gather further details.

If the patient remains unhappy with the decision of the appeal panel, the option of making a formal complaint remains.
Appendices

1. Cosmetic surgery exception list
2. Breast reduction guidance and referral form

March 2004
Appendix 1 Cosmetic surgery exception list
NHS COSMETIC SURGERY EXCEPTION CRITERIA TO EXCLUSION LIST

(A) BREAST SURGERY

1. Augmentation Mammaplasty (Breast enlargement procedure)

Patients should be considered for surgery in the following circumstances:

1. Asymmetry – eg of congenital cause or following surgery
2. Disabling psychological distress attributable directly to breast volume*

2. Female Reduction Mammaplasty (Breast reduction)

Patients should be considered for surgery in the following circumstances:

1. Physical symptoms attributable to breast size, eg back/neck pain, shoulder pain, intertrigo – providing the patient is not overweight
2. Asymmetry – usually congenital – may follow surgery
3. Disabling psychological distress attributable directly to breast size

3. Male Reduction Mammaplasty (Gynaecomastia)

Patients should be considered for surgery in the following circumstances:

1. Asymmetry – occasionally enlargement is unilateral
2. Disabling psychological distress

(iv) Mastopexy (Uplift procedure for ptotic female breast)

Patients should be considered for surgery in the following circumstances:

1. Asymmetry – eg following breast reconstruction
2. Extreme disabling psychological distress

(B) SURGERY OF HEAD AND FACE

1. Face Lift

Occasionally a face lift procedure (unilateral) can be helpful to patients with facial nerve palsy following CVA, Bell’s Palsy or following acoustic neuroma.

2. Brow Lift

No exceptional circumstances.

3. Upper Lid Blepharoplasty (Removal of excess skin of upper eyelid)

Patients should be considered for surgery in the following circumstances

1. Vision is obscured

4. Lower Lid Blepharoplasty (Removal of excess skin of lower eyelid)

Only exceptional circumstances would be severe psychological distress

5. Pinnaplasty (Correction of prominent ears)

In adults, ie above the age of 16 years, only exceptional circumstances would be severe psychological distress.

6. Repair of split earlobes

Only exceptional circumstances would be severe psychological distress

7. Rhinoplasty

Patients should be considered for surgery in the following circumstances:

1. Disruption of normal nasal pattern following trauma
2. Interference with nasal airway because of disturbed anatomy
3. Asymmetry of nose – eg congenital abnormality – bifid nose, cleft lip
4. Disabling psychological distress attributable directly to appearance of nose

8. Hair transplant

Should not be available

(C) MISCELLANEOUS

1. Abdominoplasty Apronectomy

Patients should be considered for surgery in the following circumstances:

1. Physical symptoms attributable directly to the abdominal apron, eg infection, lower back pain
2. Disabling psychological distress

2. Buttock lift )

)

3. Buttock reduction ) Not available at all

)

4. Surgery for obesity )

5. Arm and thigh reductions

Availability – following gross weight loss – will need discussion on basic principles

6. Liposuction

Not available for purely cosmetic reasons but may be needed to reduce bulk of flaps etc.

7. Tattoos

Tattoos should be referred to a Laser Clinic as this is the most appropriate method of removal.

* Disabling psychological distress is obviously a subjective measure. Significant treatment requirements (drugs or otherwise) probably represent the most objective indicator.


Appendix 2 Breast reduction guidance and referral form
Reduction mammaplasty surgery: guidance on potential referrals

The following conditions apply to all cases:

1 Absolute weight limit of 75 kg
This is imposed because of a 90% complication rate in patients above this weight.

2 Upper BMI limit of 27
This is because of variation in breast volume associated with overall body fat.

3. Minimum breast volume as assessed by bra size
There is agreement between surgeons that there should be a minimum of 500 gm tissue removed from each breast for the procedure to be justifiable. This is difficult to assess in practice, and so has been translated into minimum bra cup sizes for different chest measurements.



chest measurement (in)


cup size

32 / 34


>= E

36


>= EE

38


>= F

40/42*


>F

*once women have reached this size, they are likely to have a significant weight problem which should be addressed prior to surgery anyway



Where physical symptoms are the reason for surgery

4 Well fitting bra
Neck, back and shoulder pain are frequently attributed to breast volume, but are more likely to be due to an ill-fitting bra. There is a tendency to wear a bra with an inadequate cup size and which is too large around the chest which consequently offers no support. A well fitting bra should be acquired and worn prior to consideration of referral.

5 Physiotherapy for back pain
Where back pain is the main reason for requesting the surgery, it is suggested that poor posture is often associated with embarrassment regarding breast volume. In such cases, it is worth trying physiotherapy prior to considering suitability for surgery.

Where psychological reasons are the reason for surgery

6 Objective evidence of severe disabling psychological distress directly attributable to breast volume
The general guidelines apply and significant treatment requirements (drugs or otherwise) are taken as an objective indicator of the severity of distress.



CONFIDENTIAL

NHS COSMETIC SURGERY - EXCEPTION TO EXCLUSION LIST

: Reduction mammaplasty

Patient:


DoB:

Height:


Weight:

Bra size:


Bra fit:

- measured recently Y / N

- appears good fit Y / N

Reason for request:

Criteria that are met to consider exception:

As appropriate:

if back pain is the reason for request:

- has physiotherapy been tried? Y / N

if disabling psychological distress is the reason for request:

- has the patient required drugs or other treatment? Y / N

(please give more detail below if "yes")

Answer 2

Well, you would have to have an appendisitis before you have your appendix removed, or you can have it electivly done, but why would you want to have elective surgery.