Procedures of clinical value being limited by CCGs
CCGs are creating lists of treatments that they either don’t offer to patients or place thresholds on patient access. Increasingly these lists include treatments that are proven to be effective and beneficial to patients.
Overview
Hernia: 95 CCGs, almost half, currently have hernia repair listed in their Procedures of Limited Clinical Value (PoLCV) or threshold list. CCGs are increasingly taking a ‘watchful waiting’ approach to hernia management which could mean an increase in emergency cases and worse patient outcomes.
Cataracts: 104 CCGs, that’s over 50%, include cataract removal on their list of PoLCV and over a third, 76 CCGs, include a visual acuity threshold. Cataract removal is the most common procedure performed on the NHS and is proven to be effective. Both NICE and the Royal College of Ophthalmology state that treatment decisions should not be based on visual acuity.
Continuous Glucose Monitoring: 12 CCGs do not commission Continuous Glucose Monitors (CGM) and a further 7 CCGs only commission via independent funding request. CGM is recommended by NICE as part of diabetes management and is proven to help people manage their diabetes.
Hip and knee Replacement: 78 CCGs include hip and knee replacement on their PoLCV lists. Hip and knee replacements are proven to be effective and have been supporting people to keep mobile for over half a century.
PoLCV
‘Procedures of Limited Clinical Value’ traditionally referred to treatments that do not have sufficient data to prove their cost effectiveness or clinical benefit. It was originally applied to treatments such as alternative and complementary therapies and cosmetic procedures. Procedures included on these lists were generally not funded by NHS commissioners.[1]
However, commissioners are increasing using PoLCV as a way to control spending by limiting access to treatments and technologies that are proven to be effective. Ration Watch conducted analysis of all 195 CCGs to look at the types of procedures they include on PoLCV lists.
Ration Watch found a number of proven treatments included on PoLCV lists. Four of the treatments listed most frequently were – hernia repair, cataract removal, Constant Glucose Monitoring and hip and knee replacements. Most commonly with these procedures, CCGs are using access thresholds to limit patient access.
What we found:
Hernia
A hernia occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall, several surgical techniques exist to fix hernia. Hernia repair is one of the most common procedures performed in the UK, with around 80,000 taking place each year.[2] There is guidance on hernia repair from NICE[3] and the Royal College of Surgeons[4]. The National Institute for Health and Care Excellence (NICE) guidance states that surgical repair should be undertaken in most individuals with an inguinal hernia in order to close the defect, alleviate symptoms of discomfort and/or prevent serious complications, such as obstruction or strangulation of the hernia.[5] The Royal College of Surgeon’s guidance is clear on the impact of delaying treatment, ‘CCGs should not set criteria for referral and treatment for inguinal hernias outside that recommended in this guidance, as this approach produces worse clinical outcomes and has not been shown to be cost effective’. There is a strong evidence base and proven record of successful outcomes following hernia repair operations.
Despite this, ration watch found that 95 CCGs, almost 50%, include hernia repair on their PoLCV lists or lists of Threshold Policies. The type of policies related to hernia repair commissioning are often described as a ‘watchful waiting’ approach. Whilst this type of approach may be appropriate for some patients, using this approach more widely could mean more and more patients will only receive treatment when their condition deteriorates and they require an emergency intervention.
Cataract Removal
Cataract surgery involves replacing the cloudy lens inside your eye with an artificial one. It’s the most common operation performed in the UK, with a high success rate in improving your eyesight.[6] The Royal College of Ophthalmology has clear guidance for commissioners on the commissioning of cataracts.[7] There is also a NICE guideline in relation to cataract management.[8] The Royal College of Ophthalmology are clear on the need to treat patients early stating that the ‘presence of cataract causes disability and increases the likelihood that individuals will suffer adverse events such as falls’ and that ‘…Cataract surgery is the only effective intervention to treat cataracts and is cost effective.’[9] Both NICE and Royal College of Ophthalmology say that access to cataract removal should not be restricted on the basis of visual acuity.
Despite this guidance and associated evidence, Ration Watch found that 104, more than 50% of CCGs include cataract removal on the PoLCV or threshold lists. Alongside this, 76 CCGs include a visual acuity threshold in their commissioning policy.
Continuous Glucose Monitoring
A Continuous Glucose Monitor is a small device that you wear just under your skin. It measures your glucose (sugar) levels continuously throughout the day and night, letting you see trends in your levels and alerting you to highs and lows.[10] It helps people manage their diabetes by allowing them to constantly track their sugar levels, identify high and low trends and even sound an alarm at high and low levels. NICE guidelines in relation to the management of diabetes in adults include guidance on how to commission CGM. NICE guidance sets out clear criteria for the commissioning of CGM and the type of user that should be considered.
Despite clear guidance on the use of CGM, Ration Watch found 12 CCGs who do not commission CGM and a further 7 who will only do so via an independent funding request. That is around 10% of CCGs placing some form of barrier to CGM.
Hip and Knee Replacement
Total hip replacement and total knee replacement are proven orthopaedic interventions that have been supporting people for many years. In total around 200,000 hip and knee replacements take place each year in England.[11] There is clear evidence supporting hip and knee replacement. The National Joint Registry has highlighted the results of a patient satisfaction assessment which shows that 92% of patients describe themselves as feeling either ‘excellent’, ‘very good’ or ‘good’ six months after treatment.[12] The British Hip Society has guidelines for the commissioning of total hip replacement, which sets out the benefits – ‘Total Hip Replacement (THR) is cost effective, returning 90% of patients to their previous job, and enabling the elderly to keep independent. The National Tariff for THR is cheaper than long-term conservative treatment for osteoarthritis of the hip’.[13]
The Royal College of Surgeons have spoken out against the use of blanket bans on access to treatment, stating that ‘blanket bans do not best serve patient care.’[14] Despite this guidance and the evidence supporting access to treatment, Ration Watch found 78 CCGs currently include hip and knee replacement surgery on their PoLCV or threshold lists. Often the policy includes a BMI threshold, something not supported by the Royal College of Surgeons.
Conclusion
The inclusion of evidence based treatments on PoLCV and threshold lists will result in huge variation in the treatments patients receive. NHS England recently launched their ‘Evidence Based Interventions programme’. This set out 17 treatments where research evidence has shown that the treatments in question are not clinically effective or are only effective when they are performed in specific circumstances. This process is clinically led and based on the available evidence. NHS England’s work to assess treatments of limited value will be undermined by individual CCGs including treatments that are supported by decades of use and an effective evidence base.
What Ration Watch would like to see
Any decision on patient treatment should be based on clinical need. Ration Watch are calling on NHS England to set clear guidelines on which procedures can be included in PoLCV and threshold lists and which procedures should not be included. Where individual CCGs are seen to have an unfair policy, NHS England should intervene.
[1] Royal College of Surgeons, Procedures of Limited Clinical Value briefing, https://www.rcseng.ac.uk/-/media/files/rcs/library-and-publications/non-journal-publications/rcs-briefing–procedures-of-a-limited-clinical-value–jan-11.pdf
[2] Hernia Outcomes Campaign, http://www.herniaoutcomes.org/the-latest-report/
[3] NHS England, Abdominal Wall Hernia Management and Repair in Adults – https://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2013/11/N-SC001.pdf
[4] Royal College of Surgeons, Groin Hernia Commissioning guide – https://www.rcseng.ac.uk/-/media/files/rcs/standards-and-research/commissioning/groin-hernia-commissioning-guide_published-2016.pdf
[5] Laparoscopic surgery for inguinal hernia repair
https://www.nice.org.uk/guidance/ta83/resources/laparoscopic-surgery-for-inguinal-hernia-repair-pdf-2294817305029
[6] NHS, Cataracts – https://www.nhs.uk/conditions/cataract-surgery/
[7] RC Ophthalmology, commissioning of Cataracts https://www.rcophth.ac.uk/wp-content/uploads/2018/02/Cataract-Commissioning-Guide-January-2018.pdf
[8] NICE Guideline NG77 – https://www.nice.org.uk/guidance/ng77/chapter/Recommendations#referral-for-cataract-surgery
[9] RC Ophthalmology, commissioning of Cataracts https://www.rcophth.ac.uk/wp-content/uploads/2018/02/Cataract-Commissioning-Guide-January-2018.pdf
[10] Diabetes UK, CGM – https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/testing/continuous-glucose-monitoring-cgm
[11] NJR, Annual Report – http://www.njrreports.org.uk/Portals/0/PDFdownloads/NJR%2015th%20Annual%20Report%202018.pdf
[12] NJR Annual Report – http://www.njrcentre.org.uk/njrcentre/Portals/0/Documents/England/Reports/10th_annual_report/NJR%2010th%20Annual%20Report%202013%20B.pdf
[13] British Hip Society, Commissioning guidance – https://www.boa.ac.uk/wp-content/uploads/2014/08/Pain-arising-from-the-hip-in-adults_updated_Final.pdf
[14] Royal College of Surgeons, Smokers and overweight patients: Soft targets for NHS savings? https://www.rcseng.ac.uk/-/media/files/rcs/about-rcs/government-relations-consultation/rcs-briefing-paper-on-rationing.pdf
“In February this year, the CCG in West Kent implemented a policy to suspend all elective surgery until the end of the financial year in an attempt to save £3.2 million. More recently, Cambridgeshire and Peterborough CCG proposed a new policy requiring patients to wait a minimum of 12 weeks for surgery . While that decision was later reversed, it is a worrying example of the kind of policy we may see spreading across the country as the financial situation of the NHS continues to deteriorate. It is not just in surgery where such rationing applies: earlier this year, I responded to a debate in Westminster Hall on infertility treatment, and it was revealed that of 209 CCGs in England, just four follow in full the National Institute for Health and Care Excellence ‘s guidelines on IVF treatment.
The individual funding request process, once reserved for rare conditions, is routinely applied by CCGs for a range of treatments. In some areas, including east Berkshire, routine hip and knee replacements are now being considered only if an individual funding request is made. Analysis by The BMJ found that the number of individual funding requests has increased by 47% in the past four years.”
Twenty-five CCGs had issued no prescriptions at all. Diabetes campaigners claim just 2 per cent of patients in England have a GP prescription for Freestyle Libre, compared to 11 per cent in Scotland, 16 per cent in Wales and 35 per cent in Northern Ireland.
Read more here: https://www.independent.co.uk/news/health/diabetes-type-1-blood-sugar-theresa-may-glucose-monitor-health-nhs-postcode-lottery-a8622811.html
Fertility Fairness’ 2017 audit of England’s 208 CCGs shows a marked reduction in access to NHS-funded IVF. The vast majority of England’s CCGs – 88 per cent – do not follow national guidance and do not offer 3 NHS-funded IVF cycles. Seven CCGs have decommissioned NHS IVF or suspended and provide 0 cycles ( 3.4 per cent); 62 per cent offer just 1 NHS IVF cycle; 24 per cent provide 2 NHS IVF cycles and just 12 per cent follow national guidance and offer 3 NHS-funded IVF cycles. Approaching one in ten CCGs is currently consulting on reducing or decommissioning NHS fertility treatment.
Read more here: http://fertilitynetworkuk.org/bury-cuts-nhs-ivf/
Read more here: https://www.yorkpress.co.uk/news/17003906.2500-york-people-have-had-surgery-delayed-because-theyre-obese-or-smoke/
Read more here: https://www.theguardian.com/commentisfree/2018/sep/14/contraception-services-cuts-councils-clinics
Read more here: https://www.dailymail.co.uk/news/article-6052687/Desperate-patients-resort-paying-privately-hip-eye-surgery-NHS-waiting-times-spiral.html
Ian Eardley, senior vice president of the Royal College of Surgeons said: “The use of funding requests means patients will spend more time in pain with potential deterioration of their condition, thereby generating further costs for a system already under acute financial strain.”
Read more here: https://www.independent.co.uk/news/health/nhs-rations-operations-hip-patients-beg-treatment-cuts-funding-a8453531.html
Susan Hill, Senior Vice President of the Royal College of Surgeons said: “It is an absolute disgrace that some patients have to demonstrate what could be a life-threatening complication of a hernia, which is one of the most straightforward surgical conditions to treat. Allowing commissioning groups, not patients with their surgeon, to make a decision to operate is putting patients at unnecessary risk of serious complications.”
Read more here: https://www.telegraph.co.uk/news/2018/07/16/hernia-patients-forced-prove-debilitating-pain-granted-operations/
Baroness Delyth Morgan, chief executive at Breast Cancer Now, said: “It is totally unacceptable that any patient is being denied the reconstructive surgery they need or rushed into potentially life-changing decisions, at such a difficult time.”
Read more here: https://www.mirror.co.uk/news/uk-news/cancer-patients-whove-breast-removed-12732254
Read more here: https://www.wscountytimes.co.uk/news/health-chiefs-defend-cataract-surgery-rationing-1-8533725
The Royal National Institute of Blind People (RNIB) told the Mail it was “outraged” by the findings.
Read more here: https://www.thesun.co.uk/news/6393193/cataracts-patients-denied-surgery-nhs-trusts/
Read more here: https://www.telegraph.co.uk/news/2018/08/11/numbers-going-private-surgery-soaring-nhs-rationing-deepens/
Alison Evans, Head of Policy at Alzheimer’s Research UK, said “Reports that dementia treatments could be limited in future are deeply concerning, both for the people with dementia benefiting from medicines today, and for the thousands whose lives could be transformed by future developments in research. If the NHS begins to cut back on dementia treatments now, future treatments could face additional hurdles in reaching people living with dementia.”
Read more here: https://www.alzheimersresearchuk.org/nhs-rationing-reports-red-flag-dementia-treatment/
groups that they are not given any choice or told of any alternative treatment options other than hysterectomy by their gynaecologist.
Read more here: http://www.femisa.org.uk/images/femisa%20report%20on%20patient%20choice%20and%20nice%20compliance%209.17%20-%20final.pdf
For second eye surgery, the access requirements are often stricter and often further restrict those in need of cataract surgery. The College said it is important that patients regain as much vision as possible and are able to use both eyes together. This means that restoring sight in both eyes is essential to good visual function and their quality of life.
Read more here: https://www.rcophth.ac.uk/2017/11/cataract-rationing-survey-reveals-66-of-responding-eye-units-have-some-restrictions-to-access-surgery/
Paul Breckell, Chief Executive of charity Action on Hearing Loss said this decision “sees people with hearing loss bearing the brunt of NHS rationing… The cuts run contrary to the robust independent evidence which shows the importance of hearing aids, and the views of local people who tell us that hearing aids can be life-changing.”
Read more here: https://www.actiononhearingloss.org.uk/about-us/media/latest-press-releases/free-hearing-aids-cut-on-the-nhs-for-the-first-time/
Read more here: http://www.herniaoutcomes.org/the-latest-report/
Read more here: http://www.heartrhythmalliance.org/afa/uk/news/high-risk-patients-denied-access-to-life-saving-treatment
The joint request made by the British Obesity and Metabolic Surgery Society (BOMSS) and the Royal College of Surgeons (RCS) found some CCGs either require patients to stop smoking or for patients to have a Body Mass Index (BMI) of over 50, despite NHS England and the National Institute for Health and Care Excellence (NICE) stating that surgery is cost effective and should be considered for patients with a BMI of over 35 with a co-morbidity (a further medical condition) such as Type II diabetes, or a BMI of 40 without a co-morbidity.
This is of particular concern as NICE recommends that all adults with Type 1 diabetes should routinely self-monitor their blood glucose levels, and test themselves at least four times a day, including before each meal and before bed. For people who are frequent drivers, taking regular exercise or who are at high risk of hypos this could increase to around ten times a day.
Key findings from the report are:
Read more here: https://www.abhi.org.uk/media/1379/hip-and-knee-replacement-the-hidden-barriers.pdf
Rosey Edwards was a baby when she was diagnosed with type 1 diabetes. To ensure test her blood sugar levels, she has had to use finger prick tests. However, she tried the FreeStyle Libre testing system, which avoids the need for finger prick tests. However, because she lives in Dorset, which does not provide the device to children on the NHS, her parents Kirsty, cannot afford the £96 a month to pay for it. Rosey wrote to Theresa May appealing for her support.
In a Daily Mail article, Ross Clark explains how, after suffering with symptoms of a hernia, he attended a GP appointment where he was told that his hernia was not bad enough to quality for funding for surgery. Because he was not in pain and did not have to do heavy lifting for his job, he was told he would not be referred to a specialist. He was told if he wanted inguinal hernia surgery, he would need to access this privately.
“It is pretty galling, after having paid all that tax, to find the NHS turning its back on me and refusing to offer an operation which used to be routine. The NHS tries to justify its penny-pinching on hernia surgery by claiming a ‘watch and wait’ strategy is better where a hernia is causing no symptoms other than a painless bulge. But that misses the point, that the type I have — which accounts for 75 per cent of all hernias — might be little bother when it appears, but will tend to grow with time until it becomes painful and uncomfortable, and possibly even dangerous.” he said.
Karen Smart, a mum from Stroke, was left with barely any sight after waiting two years for a cataracts operation. As a result, she stepped out in front of a vehicle outside Derriford Hospital, suffering a fractured foot. Her family have claimed the incident would not have happened if she had been able to see the vehicle.
https://www.plymouthherald.co.uk/news/plymouth-news/mum-waiting-nhs-cataracts-operation-1558882
“North Kirklees and Greater Huddersfield, have recently released plans to introduce what they refer to as a health optimisation programme, which would restrict access to elective surgery for those who smoke or who are obese. Make no mistake, whatever title is given to the scheme, it is nothing more than a thinly hidden attempt at rationing healthcare for those in need. Smokers would be given six months to quit, and for those who are considered to be obese—measured by a body mass index of more than 30—the requirement would be to lose 10% of their body weight within 12 months.”
In July 2018, Nina Parker, a disabled grandmother, was “devastated” to hear her knee operation was “axed in the cull on replacement surgery.” Nina Parker’s health has deteriorated badly and she now needs help with basic routines such as dressing and washing. Nina was due to have a double hip and knee replacement after suffering a fracture and being told by a GP the joints were “knackered”. However, after receiving her new hips, her knee surgery was cancelled because the CCG brought in a BMI threshold of 35. Her BMI was 36.
Her husband said: “We’ve been let down by the NHS and abandoned mid-treatment. The hip replacements are a waste of money as they are useless without knees to support them.”
https://www.mirror.co.uk/news/uk-news/disabled-gran-73-devastated-after-12986514
For David (not his real name), a 47-year-old engineer with erectile dysfunction and Peyronie’s disease, an abnormal curvature during an erection caused by fibrous scar tissue under the skin, the only option for a functioning love life is a penile implant. However, despite the devastating impact that the erectile dysfunction problems were having on his life, David was told the NHS would not pay the £4,500 cost of the implant. This forced David to take out a loan to have the operation done privately.
‘Procedures of Limited Clinical Value’ (or PolCV) traditionally referred to treatments that do not have sufficient data to prove their cost effectiveness or clinical benefit. It was originally applied to treatments such as alternative and complementary therapies and cosmetic procedures. Procedures included on these lists were generally not funded by NHS commissioners.[1]
However, commissioners are increasing using PoLCV as a way to control spending by limiting access to treatments and technologies that are proven to be effective. Ration Watch conducted analysis of all 195 CCGs to look at the types of procedures they include on PoLCV lists.
Ration Watch found a number of proven treatments included on PoLCV lists. Four of the treatments listed most frequently were – hernia repair, cataract removal, Constant Glucose Monitoring and hip and knee replacements. Most commonly with these procedures, CCGs are using access thresholds to limit patient access.
Hernia | Cataract | Continuous Glucose Monitoring | Hip and knee replacement | |
---|---|---|---|---|
Airedale, Wharfedale and Craven CCG | X | X | ||
Ashford CCG | X | X | ||
Barking and Daganham CCG | X | X | ||
Barnet CCG | ||||
Barnsley CCG | X | X | X | |
Basildon and Brentwood CCG | X | X | ||
Bassetlaw CCG | X | |||
Bath and North East Somerset CCG | ||||
Bedfordshire CCG | X | X | X | X |
Bexley CCG | ||||
Birmingham and Solihull CCG | X | X | X | |
Blackburn with Darwen CCG | X | |||
Blackpool CCG | ||||
Bolton CCG | X | |||
Bradford City CCG | ||||
Bradford Districts CCG | ||||
Brent CCG | X | X | ||
Brighton and Hove CCG | X | X | ||
Bromley CCG | ||||
Buckinghamshire CCG | X | X | ||
Bury CCG | X | X | ||
Calderdale CCG | ||||
Cambridgeshire and Peterborough CCG | X | X | X | |
Camden CCG | ||||
Cannock Chase CCG | X | X | ||
Canterbury and Coastal CCG | X | X | X | |
Castle Point and Rochford CCG | X | X | X | |
Central London (Westminster) CCG | X | X | ||
Chorley and South Ribble CCG | ||||
City and Hackney CCG | X | |||
Coastal West Sussex CCG | X | X | ||
Corby CCG | X | |||
Coventry and Rugby CCG | X | X | ||
Crawley CCG | X | X | ||
Croydon CCG | ||||
Darlington CCG | X | |||
Dartford, Gravesham and Swanley CCG | X | X | X | |
Doncaster CCG | X | X | X | |
Dorset CCG | ||||
Dudley CCG | X | X | ||
Durham Dales, Easington and Sedgefield CCG | X | |||
Ealing CCG | X | X | ||
East and North Hertfordshire | ||||
East Berkshire CCG | X | |||
East Lancashire CCG | ||||
East Leicestershire and Rutland CCG | X | |||
East Riding of Yorkshire CCG | ||||
East Staffordshire CCG | X | X | ||
East Surrey CCG | X | X | ||
Eastbourne, Hailsham and Seaford CCG | X | X | ||
Eastern Cheshire CCG | X | X | ||
Enfield CCG | ||||
Erewash CCG | X | X | X | |
Fareham and Gosport CCG | X | X | ||
Fylde and Wyre CCG | ||||
Gloucestershire CCG | ||||
Great Yarmouth and Waveney CCG | X | X | ||
Greater Huddersfield CCG | ||||
Greater Preston CCG | ||||
Greenwich CCG | ||||
Guildford and Waverley CCG | X | X | ||
Halton CCG | X | X | ||
Hambleton, Richmondshire and Whitby CCG | X | |||
Hammersmith and Fulham CCG | X | X | ||
Hardwick CCG | X | X | X | |
Haringey CCG | ||||
Harrogate and Rural District CCG | X | |||
Harrow CCG | X | X | ||
Hartlepool and Stockton-on-Tees CCG | X | |||
Hastings and Rother CCG | X | X | ||
Havering CCG | X | X | ||
Herefordshire CCG | X | X | ||
Herts Valleys CCG | X | X | X | |
Heywood, Middleton and Rochdale CCG | X | X | ||
High Weald Lewes Havens CCG | X | X | ||
Hillingdon CCG | X | X | ||
Horsham and Mid Sussex CCG | X | X | ||
Hounslow CCG | X | X | ||
Hull CCG | X | |||
Ipswich and East Suffolk CCG | X | X | X | |
Isle of Wight CCG | X | X | ||
Islington CCG | ||||
Kernow CCG | X | X | ||
Kingston CCG | X | |||
Knowsley CCG | X | |||
Lambeth CCG | ||||
Leeds CCG | ||||
Leicester City CCG | X | |||
Lewisham CCG | X | X | ||
Lincolnshire East CCG | X | X | X | |
Lincolnshire West CCG | X | X | X | |
Liverpool CCG | X | X | ||
Luton CCG | X | |||
Manchester CCG | X | |||
Mansfield and Ashfield CCG | X | |||
Medway CCG | X | X | X | |
Merton CCG | X | |||
Mid Essex CCG | X | X | ||
Milton Keynes CCG | ||||
Morecambe Bay CCG | ||||
Nene CCG | X | |||
Newark and Sherwood CCG | X | |||
Newcastle Gateshead CCG | X | |||
Newham CCG | X | |||
NHS Berkshire West CCG | X | X | X | |
NHS Bristol, North Somerset and South Gloucestershire CCG | X | X | X | |
NHS South East Staffordshire and Seisdon Peninsula | X | X | ||
North Cumbria | X | X | ||
North Derbyshire | ||||
North Durham CCG | X | |||
North East Essex CCG | X | X | ||
North East Hampshire And Farnham CCG | X | X | ||
North East Lincolnshire CCG | ||||
North Hampshire CCG | X | X | ||
North Kirklees CCG | ||||
North Lincolnshire CCG | ||||
North Norfolk CCG | X | X | X | |
North Staffordshire CCG | X | |||
North Tyneside CCG | ||||
North West Surrey CCG | X | |||
North, East, West Devon CCG | ||||
Northumberland CCG | X | |||
Norwich CCG | X | X | X | |
Nottingham City CCG | X | X | ||
Nottingham North And East CCG | X | X | ||
Nottingham West CCG | X | X | ||
Oldham CCG | X | X | ||
Oxfordshire CCG | X | |||
Portsmouth CCG | X | X | ||
Redbridge CCG | X | X | ||
Redditch and Bromsgrove CCG | X | X | ||
Richmond CCG | ||||
Rotherham CCG | X | X | ||
Rushcliffe CCG | X | X | ||
Salford CCG | ||||
Sandwell and West Birmingham | X | X | ||
Scarborough And Ryedale CCG | ||||
Sheffield CCG | X | X | ||
Shropshire CCG | X | X | X | |
Somerset CCG | X | X | X | |
South Cheshire CCG | X | X | X | |
South Devon And Torbay CCG | ||||
South Eastern Hampshire CCG | ||||
South Kent Coast CCG | X | X | X | |
South Lincolnshire CCG | X | X | X | |
South Norfolk CCG | X | X | X | |
South Sefton CCG | X | X | ||
South Tees CCG | ||||
South Tyneside CCG | ||||
South Warwickshire CCG | X | X | ||
South West Lincolnshire CCG | X | X | X | |
South Worcestershire CCG | X | X | ||
Southampton City CCG | X | X | ||
Southend CCG | X | X | X | |
Southern Derbyshire CCG | X | |||
Southport and Formby CCG | X | X | ||
Southwark CCG | ||||
St Helens CCG | X | X | ||
Stafford and Surrounds CCG | X | X | ||
Stockport CCG | X | |||
Stoke on Trent CCG | X | X | ||
Sunderland CCG | ||||
Surrey Downs CCG | X | X | X | |
Surrey Heath CCG | X | |||
Sutton CCG | X | |||
Swale CCG | X | X | X | |
Swindon CCG | ||||
Tameside and Glossop CCG | X | |||
Telford And Wrekin CCG | X | X | X | |
Thanet CCG | X | X | X | |
Thurrock CCG | X | |||
Tower Hamlets CCG | X | |||
Trafford CCG | X | |||
Vale Of York CCG | ||||
Vale Royal CCG | X | |||
Wakefield CCG | X | X | X | |
Walsall CCG | X | X | ||
Waltham Forest CCG | X | |||
Wandsworth CCG | X | X | ||
Warrington CCG | X | X | ||
Warwickshire North CCG | ||||
West Berkshire CCG | X | X | ||
West Cheshire CCG | X | X | ||
West Essex CCG | X | X | ||
West Hampshire CCG | X | X | ||
West Kent CCG | X | X | X | |
West Leicestershire CCG | X | |||
West London CCG | X | X | ||
West Norfolk CCG | X | X | X | |
West Suffolk CCG | X | X | X | |
Wigan Borough CCG | X | |||
Wiltshire CCG | X | X | ||
Wirral CCG | X | X | ||
Wolverhampton CCG | X | X | ||
Wyre Forest CCG | X | X |