Hallux valgus (surgical treatment)

Submission of this form is a declaration by the clinician that this patient meets the clinical criteria set

out in the Nottinghamshire 2018 Restricted Policy for the procedure

indicated.ONCE THIS FORM IS FULLY

COMPLETED AND EVIDENCE OF CRITERIA BEING MET IS RECORDED IN PATIENT NOTES EMAIL THIS FORM TO:

MACCG.IFRteam-nottscountyccgs@nhs.net

Greater Notts and Mid Notts CCGs may withhold payment to Providers for

procedures that do not have prior approval declarations.

Retrospective audits of Declarations are performed to ensure compliance with the

Policy.

This form can also be used to indicate that a procedure meets the exclusion criteria of the

policy.

Patient DetailsName:Date of Birth:NHS No.GP Practice

Clinician DetailsName:Professional Reference Number: (GMC/NMC)Date:

Organisation NUH SFHFT MSK HH

GP / Other:

I Confirm that the patient meets the current clinical guideline / policy for the restricted procedure as detailed in the Restricted Policy 2018

I Confirm that I have explained the prior approval process to the patient ad that the patient has given consent to share their information with the

PLEASE INDICATE THE RESTRICTED PROCEDURE CRITERIA DECLARED AS MET AND RECORDED IN PATIENT NOTESBefore referral is made the referrer must confirm that the patient wishes to have surgery if offered

Requests for the removal of symptomatic bunions will ONLY be commissioned where:

Conservative measures have failed (these include trying accommodative footwear, considering orthoses and using appropriate analgesia.)

The patient suffers from severe pain on walking (not relieved by chronic standard analgesia) that causes significant functional impairment

Severe deformity (with or without lesser toe deformity) that causes significant functional impairment OR prevents them from finding adequate footwear

Recurrent or chronic ulceration or infection

The clinician should ensure that the patient fulfils all the criteria before they are referred to secondary care. Before referral patients should be informed that:

They will be in plaster for 6 weeks and unable to drive and it will take at least a further 2 months to regain full function

The prognosis for treated and untreated HV is very variable

URGENT referral should be considered where HV may be compromising the foot in association with skin ulceration, diabetes or peripheral limb ischemia (or peripheral vascular disease).

Please add any additional information below

CLINICIANS MAY USE THIS FORM TO DECLARE THAT THE INDICATED PROCEDURE IS EXCLUDED FROM THE POLICY FOR THE FOLLOWING REASON:

Emergency Reasonable suspicion of cancer It is part of reconstruction following treatment for cancer,

traumatic injury or the correction of congenital malformation Not carrying out the procedure would have an adverse

effect on physical functional development of a child