kensington & chelsea pct · web viewthe patient has tried and exhausted all the conservative...
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Designation (Please mark one): Trust Clinician Other, please specify Name of Responsible Clinician GP Practice code
Name of Trust/GP Practice and Address/Telephone
CCG Name
Chosen Provider GMC/HPC code
NHS/PAS No: Date of Decision to Treat:
Patient Name D.O.B: (dd/mm/yyyy)
Patient Address
Patient Phone number
Gender Ethnicity
Please complete: All questions must be answered
Latest version of the policy is available at:https://www.hounslowccg.nhs.uk/news,-publications-and-policies/publications.aspx?n=2010
Version 5 (April 2019)
PPwT form – Radiofrequency Denervation for Low back pain
Completion of this form is for secondary and specialist clinicians only, for North West London patients who meet NWL CCGs PPwT criteria. Any queries relating to this form will be responded to within 5 working days.
TO VALIDATE THIS REFERRAL, email it to: [email protected] only using your nhs.net email account.
PATIENT CONSENT (Applicant is requested to record patients consent within their individual health records)
I confirm that this Planned procedure with Threshold (PPwT) Form has been discussed in full with the patient.I confirm that all the access criteria have been met and this patient is therefore eligible for NHS funded treatment.
The patient is aware that they are consenting for the PPWT Team to access confidential clinical and patient identifiable information held by clinical staff involved in their care about them as a patient to enable full consideration of this funding request.
On an annual basis, the PPWT team will conduct audits on a sample of records to ensure that the thresholds required by the PPwT Policy have been met. The audits also help to ensure that the quality of our record keeping adheres to the standards outlined by the General Medical Council and/or the Nursing and Midwifery Council (or other relevant body).
The patient identifiable information will not be shared with any other organisation and to ensure confidentiality, the patient’s details will be redacted if it needs to be reviewed by the clinical Triage.
YES NO [Please indicate] Date:
1. Please state which spinal level, radiofrequency denervation is requested for:Spinal level
Laterality
2. Has this patient been treated with radiofrequency denervation previously?
3. If yes, please specify the spinal level treated previously?Spinal level
Laterality
YES NO
THRESHOLDS FOR TREATMENT: ALL thresholds must be met
1. The patient has tried and exhausted all the conservative treatments / non-surgical management of the chronic low back pain (see clinical pathway in NICE Clinical Guidance 59)
AND
YES NO
2. The patient has moderate or severe levels of localized back pain graded as 5 or more on a zero to 10 visual analogue scale, or equivalent at the time of assessment
AND
YES NO
3. Has a diagnostic medical branch block provided at least 80% improvement in pain on a visual analogue pain scale or equivalent?
YES NO
In addition, please note the following aspects of the policy
If a patient requires multiple radiofrequency denervations in a single session then these should be invoiced to CCGs as a single package of care.
NWL CCGs does not fund repeated treatment of radiofrequency denervation at same spinal level and laterality. Requests for retreatment should be made via the NWL Individual Funding Request in exceptional clinical circumstances.
NICE recommend that imaging should not be offered for people with low back pain with specific facet joint pain as a prerequisite for radiofrequency denervation.
Further details of the NWL CCG low back pain policy can be found at http://www.hounslowccg.nhs.uk/news,-publications-and-policies/publications.aspx?n=2010Supporting Information - Please provide supporting evidence as this form is subject to clinical triage.
END OF FORM
Latest version of the policy is available at:https://www.hounslowccg.nhs.uk/news,-publications-and-policies/publications.aspx?n=2010
Version 5 (April 2019)