Introduction
In England today, there are currently 207 clinical commissioning groups. These are clinically led statutory National Health Service (NHS) bodies responsible for the planning and commissioning of healthcare services for their local area. These groups were created following the Health and Social Care Act in 2012, and replaced primary care trusts (PCTs) on 1 April 2013.1 Some clinical commissioning groups have merged over the past few years, meaning that their numbers have decreased slightly from 209 in 2016 to the present number of 207.
Commissioning advice and guidance within the UK is not a new issue. In April 2011, the Audit Commission published a health briefing on reducing spending on low clinical value treatments, in which it defined low clinical value treatments as ‘treatments that are either clinically ineffective or not cost-effective’. Under the listed 34 procedures that Croydon PCT initially identified as low priority, ENT aesthetic surgery is listed under ‘potentially cosmetic interventions’.2
Local clinical commissioning group guidance can change from year to year, but an overview of indications for rhinoplasty and septorhinoplasty across the country has not yet been published. Anecdotally, a variation in guidelines has been noted between different regions, and there appears to be a ‘health lottery’ in place with regard to these procedures across England.
We aimed to examine the criteria for rhinoplasty and septorhinoplasty across all clinical commissioning groups and identify any variation in practice in England. Our secondary aim was to examine the differences in guidelines, and discuss how relevant and appropriate these are in current healthcare practice.
Materials and methods
The survey was conducted in February 2016 by simultaneously writing to all 209 clinical commissioning groups, and requesting their rhinoplasty and septorhinoplasty commissioning criteria. At the time of writing the manuscript, the current number of clinical commissioning groups stands at 207 as some clinical commissioning groups have since merged.
In a standard letter, we posed the four following questions under a freedom of information request: (1) What are your local clinical commissioning group criteria for rhinoplasty and/or septorhinoplasty?; (2) Do you currently authorise nasal surgery for post-traumatic cosmetic deformity without nasal obstruction?; (3) Do you stipulate a minimum or maximum time limit between nasal injury and assessment for rhinoplasty in order to agree funding (and, if so, what is the limit)?; and (4) Do you require an assessment of the severity of cosmetic deformity prior to agreeing the funding for rhinoplasty (and, if so, what assessment is needed)?
The clinical commissioning group responses (returned via post or e-mail) were collated. Most clinical commissioning groups sent full copies of their guidelines in response to the above questions. The responses were broadly categorised, in order to review those that funded nasal surgery with or without nasal obstruction. The full copies of clinical commissioning group guidelines were also reviewed to collect the data on other criteria for the commissioning of surgery.
Results
A total of 200 responses were received from the 209 clinical commissioning groups we approached for the requested information (response rate of 95.7 per cent). We acknowledge that some regions have unified guidance which can cover multiple clinical commissioning groups within a geographical region, and that some clinical commissioning groups have merged since the survey took place. The results of the survey have been amalgamated in Table I and we will discuss the main areas of concern below.
Tabulated summary of survey findings
* Some clinical commissioning group guidelines for rhinoplasty include ‘objective nasal deformity caused by direct trauma and the treatment is required at the time of, or soon after the acute episode and before permanent healing has occurred’, which has been interpreted as allowing manipulation under anaesthesia. CCG = clinical commissioning group; OSA = obstructive sleep apnoea
No restrictions
Ten clinical commissioning groups allow cases to be judged by an ENT consultant, and their opinion is final. One clinical commissioning group stated that septorhinoplasty is not subject to policy or restriction at all.
Individual funding request
Of the clinical commissioning groups that responded, 10.5 per cent stated that any form of rhinoplasty or septorhinoplasty needs an individual funding request for exceptional circumstances before approval.
Cosmetic improvement
No clinical commissioning group authorises purely cosmetic surgery. Fifty-one (25.5 per cent) of clinical commissioning groups will allow an objective nasal deformity or cosmetic defect to be authorised if it was the direct result of nasal trauma, even without any functional obstruction. Twenty-one clinical commissioning groups specified that a nasal deformity could be corrected if this was required as access for other procedures, such as ethmoidectomy. All of these 72 clinical commissioning groups also approve surgery for patients with cosmetic deformity with associated nasal blockage. Three clinical commissioning groups additionally stated that they would allow revision of previous nasal surgery in patients without functional blockage or nasal obstruction.
Nasal blockage
The vast majority of clinical commissioning groups (179 in total, 89.5 per cent) will allow correction of bony, alar or valve defects in the presence of nasal obstruction. However, the criteria for allowing rhinoplasty or septorhinoplasty in the presence of nasal obstruction vary greatly between individual clinical commissioning groups. Broad categories have been created in Table I, in an attempt to group different clinical commissioning groups with similar criteria into one.
Of these 179 clinical commissioning groups, 91 seem to focus on the severity of the nasal obstruction and particularly its effect on the individual patient. Sixty-three clinical commissioning groups allow surgery, providing there are severe functional problems that impact on a patient's health or cause documented medical and or airway problems. Twenty clinical commissioning groups request evidence of continuous, significant symptoms that have failed to improve after three months of medical management, which are the cause of significant symptoms or obstructive sleep apnoea (OSA). Eight clinical commissioning groups allow rhinoplasty for post-traumatic severe deformities causing total blockage and associated functional impairment.
The next largest group of 64 clinical commissioning groups concentrates on the nasal obstruction itself. Twenty-one groups allow surgery when it is deemed that septoplasty alone will not improve the obstruction present and therefore septorhinoplasty is the only effective option. Eighteen clinical commissioning groups require continuous, significant obstruction, which has not improved despite medical management, but evidence of trauma must be present, including photographic evidence of nasal shape change pre- and post-nasal injury. Seventeen clinical commissioning groups allow septorhinoplasty for severe deformity causing blockage. Eight groups require persistent blockage with failed medical management for three months in cases where septoplasty alone will not help nasal obstruction.
A small proportion (13 clinical commissioning groups) stipulate a percentage of nasal blockage, seemingly as a measure of severity. Seven clinical commissioning groups allow nasal surgery for significant, functional obstruction with at least a 30 per cent airflow reduction on at least one side. Six clinical commissioning groups require severe, continuous obstruction with 100 per cent unilateral blockage, or bilateral 50:50 per cent or 25:75 per cent blockage after failed medical management, with photographic evidence of post-traumatic change.
Congenital deformity
Most clinical commissioning groups (70.5 per cent) stated that they allow nasal surgery in patients with congenital processes such as cleft lip and in palate operations requiring cleft rhinoplasty. The remaining clinical commissioning groups did not comment on this particular indication.
Time limit
Ten clinical commissioning groups (5 per cent) stipulated time limits on eligibility for surgery following trauma; nine groups had a six-month minimum length of time from injury to offering nasal surgery, and one group restricted this time limit to two years. All remaining clinical commissioning groups did not state limitations in time.
Regional variation
We further divided our responses based on the NHS regions as defined by NHS England (i.e. North of England, Midlands and East of England, London, and South of England regional teams) in order to examine any regional variation (Table II).
Main variations in clinical commissioning group criteria based on NHS england regions
Data represent numbers of clinical commissioning groups. *Some clinical commissioning groups will consider applications for rhinoplasty as an individual funding request. NHS = National Health Service; CCG = clinical commissioning group
Out of 62 clinical commissioning groups who replied to our survey in the North of England, only 2 groups restrict all forms of septorhinoplasty surgery. The remaining 60 groups allow surgery for nasal obstruction with varying indications. Just under half of these (26 clinical commissioning groups) permit surgery without nasal blockage, where the vast majority (88 per cent) allow rhinoplasty for objective deformity following trauma and the rest for surgical access.
Out of 59 clinical commissioning groups who replied to our survey in the Midlands and East of England, only 2 groups restrict all forms of nasal surgery to individual funding requests. The remaining 57 groups request a mix of indications for surgery with nasal obstruction, including documented medical problems and photographic evidence. Thirty-one clinical commissioning groups in this region allow surgery without blockage; however, the majority of these (58 per cent) are only for surgical access reasons, with surgery being allowed by 42 per cent for traumatic deformity.
In the London region, 32 clinical commissioning groups responded to our survey. All of these groups allow surgery for patients with nasal obstruction, generally after a three-month period of observation, with significant or severe symptoms. No London clinical commissioning group allows surgery without nasal obstruction; however, 14 of these groups commented that individual funding requests may be considered, although cosmetic procedures are not routinely permitted.
In the South of England, 47 clinical commissioning groups responded. Fifteen groups restrict nasal surgery to individual funding requests only, or state that nasal procedures are not normally funded. The remaining 32 groups permit surgery in patients with varying severity of nasal obstruction, with 15 of these groups also allowing traumatic deformity to be corrected in patients without obstruction.
Discussion
The results of this survey show that the exact criteria for rhinoplasty and septorhinoplasty eligibility in individual clinical commissioning groups vary significantly across England. Some criteria are easier to demonstrate, whilst other requirements may be more challenging to prove.
Cleft rhinoplasty, as an example of nasal surgery following a congenital process, was permitted by 70.5 per cent of clinical commissioning groups. The evidence of a cleft diagnosis are easily demonstrable by referring to previous clinical letters or operation notes. This unique group of patients should be managed as part of a multidisciplinary cleft team. Whilst the majority of clinical commissioning groups do not restrict such surgery, we would suggest that these cases should not be subject to the general guidelines published.
Time limits on performing septorhinoplasty following a previous nasal injury were specified by 5 per cent of clinical commissioning groups. It is probable that presentation to hospital following significant nasal trauma will be to a patient's local hospital. Therefore, future consultation in the clinic may mean previous trauma documentation is readily available as evidence of timing. The time limits specified by those clinical commissioning groups seem reasonable, with a minimum time prior to surgery being six months following injury, mostly likely to avoid detrimental premature intervention. In addition, some stated a maximum time limit of two years after injury, presumably to limit surgery in cases where post-traumatic symptoms are unlikely to be troublesome or severe, as there has been a significant delay in presentation to secondary care.
In today's NHS climate, it appears logical that no clinical commissioning group authorises purely cosmetic surgery, and that 10.5 per cent of responding clinical commissioning groups (21 groups) restrict any form of rhinoplasty or septorhinoplasty without exceptional circumstances. Those 21 regions require exceptionality. However, 51 clinical commissioning groups will allow rhinoplasty for objective nasal deformity as a result of nasal trauma, without functional obstruction, and a few groups will allow revision of previous nasal surgery in patients without nasal blockage. This contradictory message from different clinical commissioning groups within England highlights variability in the provision of ‘non-functional’ surgery.
Although the majority of clinical commissioning groups authorise surgery for ‘functional reasons’, our results show great differences in eligibility. The largest subcategory of this group (91 clinical commissioning groups) tries to ensure that only those patients with severe obstruction causing a medical condition will be allowed to undergo surgical intervention.
Some clinical commissioning groups specifically mention OSA as a medical condition that influences qualification status for surgery, and whilst it is probably the most common condition linked with nasal obstruction, it may not always be a preceding diagnosis. The role of nasal surgery in long-term improvement of OSA patients remains lacking in great evidence at present; therefore, it seems unfair to patients that this particular condition is considered necessary to warrant surgery. It has been shown that in patients with nasal obstruction and OSA, nasal surgery can improve some sleep parameters (Epworth Sleepiness Score and Respiratory Disturbance Index),Reference Ishii, Roxbury, Godoy, Ishman and Ishii3 which may improve quality of life. A recent meta-analysis has even supported a slightly significant improvement in apnoea-hypopnoea index in patients with OSA following nasal surgery.Reference Wu, Zhao, Li, Zang, Wang and Wang4 Complications of OSA include hypertension and stroke;5 therefore, any improvement gained from nasal surgery could improve an individual's future health status and therefore be very cost-effective in the wider health economy, although this is difficult to prove.
Sixty-four clinical commissioning groups request documentation of the severity of airway blockage. There are differing measures suggested for estimating the significance of nasal blockage. Ten clinical commissioning groups rely solely on the judgement of an ENT consultant for approval, whilst 21 groups allow surgery when it is deemed that septoplasty alone will not improve the obstruction, which is decided by the listing ENT surgeon. Seventeen clinical commissioning groups allow surgery for severe nasal deformity causing blockage, which, again, is presumed to be decided by the listing clinician.
It is key to reiterate the importance of thorough assessment of the underlying cause of nasal blockage. Clear documentation of patients who require septorhinoplasty for functional improvement is needed, especially where endonasal septoplasty techniques are not sufficient to address the nasal blockage (e.g. where the nasal valve is the cause of the problem or when the correction of septal deformity requires open access). This documentation of the decision-making process is assumed to be adequate for clinical commissioning group approval, and therefore needs to be precise in regard to the indication and the desired outcome.
Thirteen clinical commissioning groups ask for quantification of nasal obstruction by stipulating a percentage of nasal blockage as a surrogate measure of severity. Some patients, with encouragement, may be able to estimate how blocked each nostril is in terms of percentage, but this is purely subjective and cannot accurately be measured clinically. This attempt at grading the severity of the problem is clinically irrelevant and practically unachievable in this form.
When searching for a more suitable potential alternative to this estimation of nasal obstruction, the literature shows shortcomings of objective measures. Objective or volumetric airflow measurements remain impractical in routine clinical use, and are not without their individual flaws. The literature, however, is more in support of subjective measures such as the Nasal Obstruction Symptom Evaluation scale.Reference Stewart, Witsell, Smith, Weaver, Yueh and Hannley6 This is a subjective, validated quality-of-life tool, which has supported the evidence that septoplasty can improve disease-specific quality of life, increase patient satisfaction and decrease medication use.Reference Stewart, Smith, Weaver, Witsell, Yueh and Hannley7 When considering functional rhinoplasty in patients with moderate or severe baseline nasal obstruction, a systematic review and meta-analysis of outcomes using the Nasal Obstruction Symptom Evaluation score showed that the post-operative scores were substantially improved for 12 months.Reference Floyd, Ho, Patel, Rosenfeld and Gordin8 The clinical commissioning groups might be more justified in recommending subjective measures such as the Nasal Obstruction Symptom Evaluation score to assess severity of nasal blockage in order to increase scientific verification.
The regional variation shown between the North of England, the Midlands and East of England, London, and the South of England is interesting, as it shows London to be the most homogeneous group and the South of England to be the least. The results from London may be more streamlined, as this certainly contains the smallest number of clinical commissioning groups and occupies the smallest geographical area. Some patterns can be seen in different regions regarding the indications for surgery in patients with nasal blockage, with some clinical commissioning groups favouring time spent having conservative or medical management, and some requesting documented health problems or medical photographs (Table I). Apart from London, of those clinical commissioning groups which allow surgery in patients with nasal obstruction, approximately half allow surgery in those without blockage, although for very different underlying indications. Similarities within regions can be drawn; however, the guidelines still remain diverse from one clinical commissioning group to the neighbouring one.
Each clinical commissioning group is responsible for the financial planning and service provision of their local area, and responds to the needs of their communities. It is therefore understandable that there is variation in the provision of rhinoplasty and septorhinoplasty, but the degree of difference is great. For instance, one clinical commissioning group does not allow either of these operations without great exception (as shown in an individual funding request), whilst another group allows these operations for patients without nasal obstruction as long as there is documentation of previous trauma.
• This article summarises the National Health Service (NHS) England clinical commissioning group criteria for septorhinoplasty
• Great variation exists between NHS England regions with regard to septorhinoplasty authorisation guidelines
• Ten per cent of clinical commissioning groups request an individual funding request to consider such nasal surgery
• Of the groups, 89.5 per cent allow septorhinoplasty in the presence of nasal obstruction
• In addition, 28.5 per cent allow surgery in patients without nasal obstruction if it was a result of trauma
• Some of the groups’ criteria are not clinically relevant and some are difficult to demonstrate in order to obtain authorisation
We therefore conclude that in order to streamline commissioning, a national guideline on the management of nasal obstruction may be helpful. Similar national guidelines within otolaryngology for grommet insertion and tonsillectomy provide evidence-based recommendations that form the basis for local commissioning guidance within England. In the future, it would be beneficial to move towards a nationally agreed guideline with evidence-based criteria for commissioning rhinoplasty and septorhinoplasty, in order to avoid disadvantaging patients in certain parts of the country. The current criteria in certain clinical commissioning groups seem not to be clinically relevant and challenging to demonstrate. The authors recommend that these are reviewed and amended for future revisions.
Competing interests
None declared
