Exceptional Referral Protocol (ERP)

Procedures not routinely provided by NHSScotland

Abdominoplasty, Apronectomy, Liposuction, Thigh/Arm Lift, Excision of Redundant Skin/Fat.
Generally any procedures after significant change in body shape - eg. massive weight loss, post-bariatric surgery.
After the conclusion of any treatment episode the patient will require to be referred back through the assessment process including clinical psychology, if referral criteria are met.

Clinical Psychology

All approved referrals will be seen by a specialist Clinical Psychologist prior to assessment by a surgeon except HIV lipodystrophy cases.
Patients with HIV associated lipodystrophy may be referred for specialist Clinical Psychology assessment if required after surgical assessment.

BMI

BMI less than or equal to 27 maintained for one year must be achieved.
In a few unique cases with significant functional impairment a higher BMI may be considered if this represents a documented weight loss of 50% starting BMI, again sustained for one year.

Considerations for treatment

Indications for referral

Significant physical limitations (eg. significantly impaired mobility).
Significant physical signs despite medical intervention (eg. severe, intractable intertrigo).
HIV associated lipodystrophy.
Significant psychological distress combined with one of the above.

Contraindications for referral

Simple cosmetic requests.
Divarication of the rectus muscle is not an indication for referral.
Caesarian section sequelae are not an indication for referral.

Waiting Times

These procedures are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Diagnostic doubt or suspicion of pre malignancy/malignancy is not covered by this protocol.
Referrals for suspicion of malignancy or pre-malignant lesions should be made via the appropriate cancer pathway.

Procedures not routinely provided by NHSScotland

Excision of benign skin or subcutaneous lesions including xanthelasma.

Clinical Psychology

All approved referrals may be seen by a specialist Clinical Psychologist at the discretion of the surgical team.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Indications for referral

Issues which may allow consideration of surgical removal include unavoidable recurrent trauma and recurrent/risk of infection. Please make this clear if this is the reason for referral.
Lesions causing functional impairment.

Contraindications for referral

Benign lesions causing no functional impairment will not be removed by NHSScotland.

Waiting Times

These procedures are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not routinely provided by NHSScotland

Upper and Lower blepharoplasty - surgery for removal of excess skin and/or ‘eye-bags’.

Clinical Psychology

All approved referrals will be seen by a specialist Clinical Psychologist.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Indications for referral

Surgery may be considered where there is restriction of the visual field by the excess skin. Visual field tests to be carried out prior to referral.

Contraindications for referral

Surgery will not be considered where a perception of tiredness or ageing is the primary concern.
Treatment for xanthelasma is not provided.

Waiting Times

Blepharoplasty for restricted visual fields affecting primary gaze is subject to 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not routinely provided by NHSScotland

All procedures primarily to change the appearance of the breast in size, shape or position.
Patients undergoing primary surgery for breast cancer should be considered under the appropriate pathway.
Where clinical appearance does not match patient perception.

Clinical Psychology

All approved referrals will be seen by a specialist Clinical Psychologist.
Patients undergoing reconstructive surgery may not require psychological assessment. This decision will be at the discretion of the surgical team.

BMI

Greater than or equal to 20 and less than or equal to 27.
BMI less than or equal to 35 may be considered in patients undergoing a planned programme of reconstructive breast surgery.

Considerations for treatment

Specific to individual procedures, see ‘specific procedures’ list below for links to relevant sections.
Patients with asymmetry may require one or more of procedures described below.
Photo triage may be used. Local arrangements may be made for photographs. Patients should be advised in advance of this possibility.
Surgery to reverse the normal ageing or post-involutional changes will not be supported.

Specific Procedures

Breast Augmentation

Mastopexy

Breast Reduction

Breast Implant Complications

Gynaecomastia

Inverted Nipple Surgery

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not routinely provided by NHSScotland

Surgery for lifting one or both sides of the neck, face and brow.
All types of facelift, brow lift, neck lift.

Clinical psychology

Referral to a specialist Clinical Psychologist will be made at the discretion of the surgical team.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Indications for referral

Where there is a specific, relevant underlying cause, please make this clear in any referral.
Referrals for brow lift may be considered where there is a demonstrable visual field defect. Visual field tests to be carried out prior to referral.
Indications may include patients with collagen diseases (e.g. cutis laxa) or facial palsy.

Contraindications for treatment

Treatment simply to reverse the normal ageing process will not be supported.
All referrals for simple age related changes with no underlying cause will be returned.

Waiting times

These patients are not subject to the 18 Weeks Referral to Treatment however brow lift for restricted visual fields is subject to the 18 weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not usually provided by NHSScotland

Grafting or other techniques to restore hair growth to an area of alopecia.

Clinical Psychology

Referral to specialist Clinical Psychologist may be made at the discretion of the surgical team.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Indications for referral

Following trauma (including surgery), burns, or rare congenital conditions.

Contraindications for referral

Referrals for normal male pattern baldness will not be considered.

Waiting Times

These patients are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment of these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not usually provided by NHSScotland

Surgery to alter the form of the external ear after the age of 18.

Clinical Psychology

All approved referrals aged 5 to 18 will be seen by a specialist Clinical Psychologist.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Indications for referral

Prominent ear surgery requested under the age of 18.

Contraindications for referral

Pinnaplasty will not be supported after the age of 18.

Waiting Times

These patients are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment of these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not usually provided by NHSScotland

All procedures where the primary aim is to alter the appearance of the nose.
Congenital anomalies (e.g. nasal deformity associated with cleft lip) will usually be in a continuing programme of treatment and are not subject to the protocol.

Clinical Psychology

Referrals only for nasal obstruction do not require specialist Clinical Psychology.
Where surgery will cause a change in appearance as a secondary outcome clinical psychology input should be considered prior to the procedure.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Indications for referral

A deviated nose and functional problem of the nasal airway.
Procedures to alter the appearance of the nose after trauma will usually be supported if the patient has sought initial medical attention within one year of injury.

Contraindications for referral

Simple cosmetic rhinoplasty will not be supported.

Waiting Times

Procedures for nasal obstruction are subject to the 18 Weeks Referral to Treatment Standard.
All other indications for rhinoplasty are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not usually provided by NHSScotland.

Any treatment for the purpose of removing or reducing a tattoo.
Professional tattoos are usually incompletely removed by laser treatment.
Repair of ear spacer defects.

Clinical Psychology

All approved referrals will be seen by a specialist Clinical Psychologist

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Treatment for post traumatic or iatrogenic tattooing will be supported.
Tattoo removal is not usually supported unless the tattoo was gained in the absence of consent.
Tattoo removal other than of face, neck or hands is most unlikely to be supported.
Piercings – acutely torn earlobes should be referred for repair to A&E.
Torn earlobes will be considered for treatment.
Stretched piercings and ear spacer defects will not be considered for treatment.

Waiting Times

These patients are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not usually provided by NHSScotland.

Laser and microsclerotherapy.
Treatment for facial flushing or background erythema is not offered.
Treatment may lead to incomplete resolution despite multiple sessions.

Clinical Psychology

Referral to a specialist Clinical Psychologist will be at the discretion of the surgical team.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for this type of surgery.

Considerations for treatment

Treatment is only supported for severe lesions on the face, and will be based on severity which will be determined by a regional vetting panel.
All referrals will require formal medical photography.
A maximum of 6 treatment sessions will be offered following initial assessment.

Waiting Times

These patients are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not routinely provided by NHSScotland.

Procedures performed primarily to alter the appearance of the external genitalia.
In the presence of physical dysfunction referral to gynaecology/urology should be considered.
In the presence of psychological/psychosexual dysfunction primary psychological referral may be more appropriate.

Clinical Psychology

All approved referrals will be seen by a specialist Clinical Psychologist.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for surgery.

Considerations for treatment

Indications for referral

Significant functional impairment which must be confirmed by an appropriate specialist (gynaecology or urology).

Contraindications for referral

Cosmetic genital surgery is not supported by NHSScotland.

Waiting Times

These patients are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional case basis in line with the guidelines contained in this protocol.

Procedures not routinely provided by NHSScotland

76% of the population have atrophic acne scarring. Only patients considered to have severe facial scarring will be considered.
Keloid and hypertrophic scars will be considered under a separate scar management pathway.

Clinical Psychology

All approved referrals will be seen by a specialist Clinical Psychologist.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for surgery.

Considerations for treatment

Treatment will be based on severity which will be determined by a regional vetting panel.
Formal medical photography will be required.

Indications for referral

Severe facial scarring.

Contraindications for referral

Active acne. Roaccutane within the last 12 months.

Waiting times

These patients are not subject to the 18 Weeks Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional basis in line with the guidelines contained in this protocol.

Procedures not routinely provided by NHSScotland

Hair reduction other than severe facial hair in females.

Clinical Psychology

All approved referrals will be seen by a specialist Clinical Psychologist.

BMI

There are no specific BMI restrictions.
If BMI is significantly raised consider carefully whether patient is appropriate for surgery.

Considerations for treatment

Treatment will be based on severity which will be determined by a regional vetting panel.
Treatment for hair growth secondary to flap surgery.
Formal medical photography will be required.
A formal reassessment of severity, including specialist clinical psychology, will be carried out after 6 treatments, and treatment will only be continued following reassessment.

Indications for referral

Dark, thick, terminal coarse hair.
Severe abnormal facial male pattern hair growth in a female.

Contraindications for referral

White, grey, blonde, or red hair will not respond to laser treatment.
Fine hair will not be treated.
Hairline, eyebrows, and upper lip will not be treated.

Waiting times

These patients are not subject to the 18 week Referral to Treatment Standard.
See Annex A for Laser Hair Reduction Score

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional basis in line with the guidelines contained in this protocol.

Procedures not routinely provided by NHSScotland

Specialist treatment is only offered to those patients with excessive sweating.
Botulinum toxin injections will only be considered in those who have failed to respond to other treatment options and at least by sweat test are qualified to have hyperhidrosis.

Clinical Psychology

Referral to a specialist Clinical Psychologist may be made at the discretion of the clinical team.

BMI

There are no specific restrictions but a significantly raised BMI may be a factor.

Considerations for treatment

Indications for referral

Excessive hyperhidrosis and where treatment options in Primary Care have proven to be unsuccessful.

Contraindications for referral

Where sweating may be secondary to an underlying cause (patients should be referred for appropriate investigations).
Treatment will not be available to patients who do not have hyperhidrosis.

Waiting times

These patients are not subject to the 18 week Referral to Treatment Standard.

Treatment for these conditions is not routinely offered by NHSScotland and can only be provided on an exceptional basis in line with the guidelines contained in this protocol.

Laser Hair Reduction Score

NOTE: Underlying endocrine conditions must be investigated and if appropriate treated prior to referral.

Note: Each site section is scored 1 to 4 and total to merit funding must be 7 or above

Vetting Panels, Appeals and Monitoring arrangements

To support and monitor the impact of the revised Protocol this document sets out details on the composition of vetting panels (which will be established by local teams as necessary), the appeals process and ongoing monitoring of the protocol.

Composition of Vetting Panels

• A Clinical Psychologist (from one of the Regional Psychology Services)
• Admin support
• A Senior Nurse
• Consultant x 2
• A General Practitioner

Frequency

Minimum of one meeting per month.

Appeals Process

Where a vetting panel rejects a case the individual concerned has a right to appeal the decision of the original vetting panel through the following process:

Level 1 – A full case review by the original local vetting panel considering any additional information provided by the patient/GP.

Level 2* – Case sent to an independent panel for review.

Level 3 – Formal Health Board complaints procedure.

* A level 2 review can only be triggered if the patient contests the outcome of the level 1 review. 

Monitoring/Review of Protocol

The Exceptional Referral Working Group will continue to meet annually to look at the frequency of procedures and feedback into the process to ensure a level playing field across NHSScotland.

• The first review will take place 12 months after the launch of the revised protocol.

The following data will be collected by each Unit and presented at the annual meeting:

• Number of referrals received.
• Number of referrals initially removed by triage.
• Number of referrals entering the vetting panel system
• Number of referrals successful at the vetting panel
• Number of referrals unsuccessful at the vetting panel
• Number of level 1 appeals Number of level 2 appeals
• Number of complaints received Number of clinical psychology referrals.

Sample testing - 3 times a year a sample of cases will be vetted by another panel. This will involve a random 10 cases being selected by each Unit and sent on rotation to another vetting panel for consideration.